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Bioterrorism preparedness: A survey of Nebraska health care institutions
Bioterrorism preparedness: A survey of Nebraska health care institutions Virginia Helget, RN, MSN, CICa Philip W. Smith, MDa,b Omaha, Nebraska In March 2001, a 6-question survey was mailed to all hospitals and long-term care facilities in Nebraska to assess preparedness for bioterrorism. Only half of the respondents at that time believed that bioterrorism was something their community was likely to experience. We found that most facilities (98%) believed that they were unprepared for a bioterrorism event, and many did not know whom to contact in the event of such an emergency. We concluded from the results of the survey that the greatest needs to facilitate preparation were policies and procedures, identification of contacts, medications, protective equipment, laboratory support, and communication. (Am J Infect Control 2002;30:46-8.)
The reality of bioterrorism has unfortunately been confirmed by recent anthrax cases reported in the United States. However, the concept of biologic warfare is not new. Nationwide, significant preparations for a possible bioterrorist attack had been undertaken even before the recent attacks. The Nebraska Infection Control Network (NICN) is a nonprofit statewide infection control organization with representatives from Nebraska hospital and nursing home associations, the state health department, the Association for Professionals in Infection Control and Epidemiology (APIC) chapters, medical schools, and consumers. The NICN was founded in 1980 and has focused on providing infection control training and educational programs and a statewide system of regional consultants available for questions. With the assistance of a grant from the State of Nebraska Department of Health, the NICN conducted a survey of hospitals and nursing homes in the state in the summer of 2001 to assess bioterror-
From the Nebraska Infection Control Networka and University of Nebraska Medical Center.b Reprint requests: Virginia Helget, Nebraska Infection Control Network, PO Box 6521, Omaha, NE 68106. Copyright © 2002 by the Association for Professionals in Infection Control and Epidemiology, Inc. 0196-6553/2002/$35.00 + 0 17/49/122254 doi:10.1067/mic.2002.122254
46
ism preparedness. We present here the results of the baseline preparedness survey.
METHODS In March 2001, a 6-question survey was prepared and sent to all Nebraska hospitals, long-term care facilities (LTCFs), and assisted living facilities. The survey was planned to be short and easy to complete. The questionnaire asked respondents about overall facility and community preparedness, specific deficiencies in preparedness, anticipated telecommunications problems, and contacts in the event of a bioterrorism attack. Surveys were returned during the next 2 months.
RESULTS Of the 900 surveys mailed to Nebraska facilities, 131 were completed (14.6% response rate). Most responses were from LTCFs (43.5%), followed by hospitals (29%) and assisted living facilities (9.2%). The remaining 18.3% came from combined hospitals and LTCFs. Respondents represented various facilities, most being small to medium in size. Teaching and tertiary care facilities were represented in the responses, however. The responses were representative of the proportional membership of the NICN and of the demographics of health care institutions in Nebraska, with a majority being LTCFs.
Helget and Smith
February 2002 47
Table 1. What do you need to be prepared for a bioterrorism event?
Table 3. Who are your contacts in the case of a bioterrorism event?
% of responses (N = 131) Internal policies and procedures Community policies and procedures Names of contacts Medications Protective equipment Laboratory support Communication devices Other
17 16.5 14.5 13 13 12 10 4
Table 2. What telecommunications difficulties do you anticipate would prevent rapid communication of information? % of responses (N = 131) Unknown Interruption in phone service Power outage/overload No telecommunications difficulties Radios needed Names of contacts Real-time surveillance Ham operators needed
41.4 27.2 10.0 8.6 7.1 2.9 1.4 1.4
In March and April 2001, only 49% of the respondents believed that bioterrorism was something their community might encounter. Ninety-eight percent of all respondents said that they were not prepared for a bioterrorism event. Hospitals recognized the potential threat more frequently than other facilities. Respondents were asked about specific deficiencies that would need to be addressed to prepare for a bioterrorism event, and responses are listed in Table 1. We also asked about telecommunications difficulties that would prevent rapid communication of information, and responses are detailed in Table 2. Nine percent of respondents felt that no telecommunications difficulties would occur. When asked to list their contacts if bioterrorism was encountered, many services and people were indicated. Law enforcement, the emergency department, the local hospital, and local law enforcement were most frequently named (Table 3). The health department and the FBI and other federal agencies were named by fewer than 10% of respondents. Thirty percent did not know whom to contact.
% of responses (N = 131) Unknown Local law enforcement Emergency services Health department Local hospital Federal agency (eg, FBI) Civil defense Public health laboratory Administration Poison control center Military
30 20 11 9 8 7 6 4 2 2 1
DISCUSSION The low response rate (14.6%) in our survey probably reflects the belief by many at the time that bioterrorism was unlikely to occur in their community. The vast majority of institutions surveyed in our state in the spring of 2001 did not feel prepared for a bioterrorist attack (98%). This may reflect the fact that national and state planning efforts had not yet been translated to local protocols. This is of concern since local health care institutions would be expected to be intimately involved in any bioterrorist attack. Specific areas of deficiency that were identified included lack of internal policies/procedures (17%), lack of community policies/procedures (17%), lack of clarification of which external agency to contact in an emergency (15%), lack of medication available in the event of a crisis (13%), lack of protective equipment availability (13%), lack of laboratory backup (12%), and inadequate communication devices (10%). Respondents identified a number of potential telecommunications difficulties in the event of a bioterrorist attack, including lack of computers and fax machines if power were lost, inadequate phone availability, lack of real-time surveillance, and lack of ready contact with public health agencies. These concerns were greater in rural areas. The most commonly identified contact in the event of a bioterrorist attack was local law enforcement agencies (20%). After that, most would turn to local health care providers or health departments. Many respondents expressed the need for local protocols that identified prioritized contacts in the event of an emergency.
Helget and Smith
48 Vol. 30 No. 1 Significant preparatory efforts for a bioterrorist attack were in place long before September 11, 2001. These include the Centers for Disease Control and Prevention strategic plan,1 establishment of a national laboratory response network,1 the national pharmaceutical stockpile program, and the APIC bioterrorism readiness plan.2 Many states and cities had already initiated bioterrorism preparations, and 24-hour hotlines had been suggested.3 A bioterrorism simulation drill in May 2000 helped to define bioterrorism preparedness,4 and a number of problems were identified including issues of leadership, decision-making, communication, and resource distribution. Since the survey, numerous bioterrorism-related educational conferences have occurred across the state. The NICN has collaborated with the state health department to present several programs for infection control and other professionals on this topic. State, local, and institutional readiness plans are being rapidly developed, and a repeat survey is planned to assess the progress that has been made and areas still needing improvement.
CONCLUSION At the time of the survey (spring 2001), fewer than half of respondents believed that their community would likely experience a bioterrorism attack, a result that would certainly be different if a survey were conducted today. Our survey demonstrated significant concern about preparedness for a bioterrorist attack at the local level and identified some areas for concentration of efforts to increase bioterrorism preparedness. The fact that only 20% understood the importance of contacting local law enforcement in a bioterrorist attack is surprising and would probably be quite different in a survey conducted today. References 1. Centers for Disease Control and Prevention. Biological and chemical terrorism: strategic plan for preparedness and response. Recommendations of the CDC Strategic Planning Workgroup. MMWR Morb Mortal Wkly Rep 2000;49(RR-4):1-14. 2. APIC Bioterrorism Task Force and CDC Bioterrorism Working Group. APIC/CDC bioterrorism readiness plan: a template for healthcare facilities. 1999. Available at http://www.apic.org/bioterror/. 3. Khan AS, Ashford DA. Ready or not—preparedness for bioterrorism. N Engl J Med 2001;345:287-9. 4. Inglesby TV, Grossman R, O’Toole T. A plague on your city: observations from TOPOFF. Clin Infect Dis 2001;32:436-45.
The reality of bioterrorism has unfortunately been confirmed by recent anthrax cases reported in the United States. However, the concept of biologic warfare is not new. Nationwide, significant preparations for a possible bioterrorist attack had been undertaken even before the recent attacks. The Nebraska Infection Control Network (NICN) is a nonprofit statewide infection control organization with representatives from Nebraska hospital and nursing home associations, the state health department, the Association for Professionals in Infection Control and Epidemiology (APIC) chapters, medical schools, and consumers. The NICN was founded in 1980 and has focused on providing infection control training and educational programs and a statewide system of regional consultants available for questions. With the assistance of a grant from the State of Nebraska Department of Health, the NICN conducted a survey of hospitals and nursing homes in the state in the summer of 2001 to assess bioterror-
From the Nebraska Infection Control Networka and University of Nebraska Medical Center.b Reprint requests: Virginia Helget, Nebraska Infection Control Network, PO Box 6521, Omaha, NE 68106. Copyright © 2002 by the Association for Professionals in Infection Control and Epidemiology, Inc. 0196-6553/2002/$35.00 + 0 17/49/122254 doi:10.1067/mic.2002.122254
46
ism preparedness. We present here the results of the baseline preparedness survey.
METHODS In March 2001, a 6-question survey was prepared and sent to all Nebraska hospitals, long-term care facilities (LTCFs), and assisted living facilities. The survey was planned to be short and easy to complete. The questionnaire asked respondents about overall facility and community preparedness, specific deficiencies in preparedness, anticipated telecommunications problems, and contacts in the event of a bioterrorism attack. Surveys were returned during the next 2 months.
RESULTS Of the 900 surveys mailed to Nebraska facilities, 131 were completed (14.6% response rate). Most responses were from LTCFs (43.5%), followed by hospitals (29%) and assisted living facilities (9.2%). The remaining 18.3% came from combined hospitals and LTCFs. Respondents represented various facilities, most being small to medium in size. Teaching and tertiary care facilities were represented in the responses, however. The responses were representative of the proportional membership of the NICN and of the demographics of health care institutions in Nebraska, with a majority being LTCFs.
Helget and Smith
February 2002 47
Table 1. What do you need to be prepared for a bioterrorism event?
Table 3. Who are your contacts in the case of a bioterrorism event?
% of responses (N = 131) Internal policies and procedures Community policies and procedures Names of contacts Medications Protective equipment Laboratory support Communication devices Other
17 16.5 14.5 13 13 12 10 4
Table 2. What telecommunications difficulties do you anticipate would prevent rapid communication of information? % of responses (N = 131) Unknown Interruption in phone service Power outage/overload No telecommunications difficulties Radios needed Names of contacts Real-time surveillance Ham operators needed
41.4 27.2 10.0 8.6 7.1 2.9 1.4 1.4
In March and April 2001, only 49% of the respondents believed that bioterrorism was something their community might encounter. Ninety-eight percent of all respondents said that they were not prepared for a bioterrorism event. Hospitals recognized the potential threat more frequently than other facilities. Respondents were asked about specific deficiencies that would need to be addressed to prepare for a bioterrorism event, and responses are listed in Table 1. We also asked about telecommunications difficulties that would prevent rapid communication of information, and responses are detailed in Table 2. Nine percent of respondents felt that no telecommunications difficulties would occur. When asked to list their contacts if bioterrorism was encountered, many services and people were indicated. Law enforcement, the emergency department, the local hospital, and local law enforcement were most frequently named (Table 3). The health department and the FBI and other federal agencies were named by fewer than 10% of respondents. Thirty percent did not know whom to contact.
% of responses (N = 131) Unknown Local law enforcement Emergency services Health department Local hospital Federal agency (eg, FBI) Civil defense Public health laboratory Administration Poison control center Military
30 20 11 9 8 7 6 4 2 2 1
DISCUSSION The low response rate (14.6%) in our survey probably reflects the belief by many at the time that bioterrorism was unlikely to occur in their community. The vast majority of institutions surveyed in our state in the spring of 2001 did not feel prepared for a bioterrorist attack (98%). This may reflect the fact that national and state planning efforts had not yet been translated to local protocols. This is of concern since local health care institutions would be expected to be intimately involved in any bioterrorist attack. Specific areas of deficiency that were identified included lack of internal policies/procedures (17%), lack of community policies/procedures (17%), lack of clarification of which external agency to contact in an emergency (15%), lack of medication available in the event of a crisis (13%), lack of protective equipment availability (13%), lack of laboratory backup (12%), and inadequate communication devices (10%). Respondents identified a number of potential telecommunications difficulties in the event of a bioterrorist attack, including lack of computers and fax machines if power were lost, inadequate phone availability, lack of real-time surveillance, and lack of ready contact with public health agencies. These concerns were greater in rural areas. The most commonly identified contact in the event of a bioterrorist attack was local law enforcement agencies (20%). After that, most would turn to local health care providers or health departments. Many respondents expressed the need for local protocols that identified prioritized contacts in the event of an emergency.
Helget and Smith
48 Vol. 30 No. 1 Significant preparatory efforts for a bioterrorist attack were in place long before September 11, 2001. These include the Centers for Disease Control and Prevention strategic plan,1 establishment of a national laboratory response network,1 the national pharmaceutical stockpile program, and the APIC bioterrorism readiness plan.2 Many states and cities had already initiated bioterrorism preparations, and 24-hour hotlines had been suggested.3 A bioterrorism simulation drill in May 2000 helped to define bioterrorism preparedness,4 and a number of problems were identified including issues of leadership, decision-making, communication, and resource distribution. Since the survey, numerous bioterrorism-related educational conferences have occurred across the state. The NICN has collaborated with the state health department to present several programs for infection control and other professionals on this topic. State, local, and institutional readiness plans are being rapidly developed, and a repeat survey is planned to assess the progress that has been made and areas still needing improvement.
CONCLUSION At the time of the survey (spring 2001), fewer than half of respondents believed that their community would likely experience a bioterrorism attack, a result that would certainly be different if a survey were conducted today. Our survey demonstrated significant concern about preparedness for a bioterrorist attack at the local level and identified some areas for concentration of efforts to increase bioterrorism preparedness. The fact that only 20% understood the importance of contacting local law enforcement in a bioterrorist attack is surprising and would probably be quite different in a survey conducted today. References 1. Centers for Disease Control and Prevention. Biological and chemical terrorism: strategic plan for preparedness and response. Recommendations of the CDC Strategic Planning Workgroup. MMWR Morb Mortal Wkly Rep 2000;49(RR-4):1-14. 2. APIC Bioterrorism Task Force and CDC Bioterrorism Working Group. APIC/CDC bioterrorism readiness plan: a template for healthcare facilities. 1999. Available at http://www.apic.org/bioterror/. 3. Khan AS, Ashford DA. Ready or not—preparedness for bioterrorism. N Engl J Med 2001;345:287-9. 4. Inglesby TV, Grossman R, O’Toole T. A plague on your city: observations from TOPOFF. Clin Infect Dis 2001;32:436-45.