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HealthThe Economy

TOPOFF Exercise Identified Health Care Deficiencies

Months before senior-level government officials participated in a simulate a deadly smallpox biological weapons attack called “Dark Winter,” the Department of Justice[i]  held an exercise called TOPOFF.

The May 2000 exercise tested the readiness of top government officials to respond to terrorist attacks in multiple geographic locations. The drill simulated a chemical weapons event in Portsmouth, New Hampshire, a radiological event in the greater Washington, DC area, and a bio-weapon event in Denver, Colorado. The Bio-weapon event involved the aerosol release of “Yersinia pestis,” the bacteria that causes plague.

TOPOFF tested the ability of the public health system and its supporting infrastructure to react to a Biological event.  It was thought that addressing those challenges would strengthen the capacity of public health agencies to react.

The notional exercise presented thousands of panicked persons flooding into emergency departments, calls for people to stay home, and the use of media communication through a “virtual network.”

During the exercise, medical officials in Denver sought assistance to determine treatment protocols and protective measures. Eventually, hospital staffers were calling in sick. Antibiotics and ventilators were becoming scarce. The governor restricted travel into or out of Denver, and officials reported cases of the plague outside Denver.

Quickly, Denver hospitals reached capacity while the number of bodies and in morgues reach critical levels. By the third day of the exercise, hospitals were understaffed with insufficient antibiotics, ventilators, and beds to meet the demand. Medical Care was beginning to shut down.

There were problems pushing antibiotics from stockpiled delivery points to people who needed the treatment.  Bordering states were alerted of the epidemic. England and Japan reported cases. Both Japan and the World Health Organization (WHO) requested technical assistance from the Center for Disease Control (CDC).

Key findings included:

  • Findings that the systems and resources in place were unable to manage a biological event.
  • Problems existed in leadership and decision-making and,
  • Decision-makers had difficulties prioritizing and distributing scarce resources.

Reports on the exercise noted that political leadership was essential to manage the consequences of a severe epidemic after a buyout terrace event. In such a crisis, effective decision making is paramount and requires strong, capable and clear leadership sustained by a council of a multi-disciplinary body of experts.

After action reports made it clear that decision-making in such a crisis requires information sources and analytical capabilities designed to deliver real-time data showing:

  • The number and location of persons infected.
  • Epidemiological information to determine sources of exposure to an agent and,
  • Systems that allowed decision-makers to communicate efficiently with hospitals and the public health community.

Those participating found out that meeting such a crisis required clear principles to allow decision-makers to assign priorities for the use of scarce resources and to implement such decisions during an unfolding epidemic crisis.  TOPOFF made it clear that public health resources, in place at that time, would not be enough to meet the requirement.

The exercise reminded political leaders that during an epidemic of contagious disease, hospitals would quickly need to care for overwhelming numbers of patients.  During such a crisis, it would be necessary to manage shortages of personnel, medicines, and equipment; and provide the security needed for crowd control, for the provision of safety for Health Care workers and patients and even for the info isolation of contagious patients.

Recommendations included the need to formulate clear, scientifically, and politically sound principles for the containment of highly contagious disease outbreaks in large urban communities.

The exercise identified the need for decisions regarding patient isolation, and regarding travel advisories, home curfews, the closure of airports and highways, and attempts to quarantine cities and states must be balanced against the practical feasibility of such measures while considering the implications for civil liberties.

In conclusion, the capacities and responsibilities needed in the event of a Bio-weapons attack exceeded available resources.


[i]  The 1996 Defense Against Weapons of Mass Destruction Act, commonly referred to as the “Nunn-Lugar-Domenici Act,” designates the Department of Defense as the lead agency to enhance domestic preparedness for responding to and managing the consequences of terrorists’ use of weapons of mass destruction.

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Michael McGreer Mesquite, Nevada
Dr. Michael Manford McGreer is managing editor of and writes on issues that impact public policy.

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