Even successful responses can highlight areas in which improvement is needed in the training of responders, which is one reason – a big one – why the sharing of lessons learned is so important. Enhanced training that includes lessons from real-world situations and events can help responders familiarize themselves with their own roles, the policies of their agencies, and the unique challenges of working with other agencies during a multi-agency extended response.
In December 2009, the United Campus Ministry at the University of New Hampshire (UNH) hosted an event that involved a “drumming circle” in which participants brought their own drums and played them, along with other enthusiasts. During the two-hour event, about 70 people played and interacted with one another – while also socializing, dancing, and dining. Unfortunately, some of the animal-hide drums had been contaminated with a naturally occurring strain of anthrax that aerosolized while the participants were drumming away (on a total of 59 drums). At least one participant ingested the toxic spores.
Several weeks later, a woman who had participated in the drumming circle was diagnosed at Massachusetts General Hospital with gastrointestinal anthrax, the first case ever recorded in the United States; gastrointestinal anthrax is more commonly transmitted by the consumption of contaminated meat. The patient later recovered.
To control any further spread of anthrax, seven federal, 19 state, and 23 local agencies (from communities in areas near the University of New Hampshire in Durham) worked together to conduct the epidemiological investigation, prophylaxis activities, and remediation and recovery operations that were required. The response was successful – the New Hampshire Department of Health and Human Services offered prophylaxis to 84 potentially exposed people who had been at or near the community center during or after the drum-circle event; of the 59 drums, only two were found to be contaminated with anthrax and were disposed of.
No one else is known to have contracted gastrointestinal anthrax from the event. However, like many of the relatively rare hazard responses that involve a large number of agencies, the response highlighted several opportunities for improvements in training.
Minor Errors & Omissions – With Potentially Major Implications
During the response and follow-up operations, carried out from December 2009 to April 2010, the New Hampshire State Emergency Operations Center (EOC) used WebEOC to track and manage information. Although some EOC staff members uploaded daily situation reports to WebEOC, not all staff members had been properly trained on and familiar with the WebEOC’s full capabilities. Because they were not able to take full advantage of the system’s real-time information-sharing features, cooperation between the numerous agencies participating was not as effective as it should have been, making it more difficult for the EOC to provide up-to-date timelines and the documentation of response efforts to emergency responders in the field. The incident after-action report notes that better training could have helped EOC staff members use WebEOC more effectively, and that could have increased situational awareness.
During the response efforts, the New Hampshire Department of Health and Human Services coordinated public information dissemination through the public information officers at each of the agencies participating. Throughout the lengthy response operations, however, three different people held the position of lead spokesperson, who served as the direct liaison with the media and public. For each transition, public information officers from each of the responding agencies had to provide in-depth briefings about: (a) everything they had done up to that point; and (b) their own operational procedures. The added workload not only caused some confusion among the agencies (and in the media), but also contributed to the dissemination of a few muddled or inconsistent messages. The after-action report recommends that, whenever possible, a single well trained spokesperson be prepared to represent agencies during long-term multi-agency responses.
The after-action report also highlights several areas for training improvement – e.g., maintaining a secure perimeter, and ensuring that all persons accessing the scene be required to use protective personal equipment (PPE). Another problem highlighted was that, although local police departments conducted environmental sampling (along with other agencies) and carried out daily drive-bys of the site, no one agency had been designated to provide a secure 24-hour presence to prevent unauthorized persons from entering the response zone. Because of that omission, some people not only entered the building unimpeded but also without the proper PPE. Although no one was contaminated by doing so, the effects during other hazardous materials events could be dire. With proper PPE training and a secure perimeter, responders can almost always ensure that contaminants are not spread beyond the disaster area.
Overall, though, the responders from federal, state, and local (New Hampshire) levels were able to contain the gastrointestinal anthrax contamination, and no other cases beyond the first patient were reported. In addition, the responders were able to work together toentify the likely source of the contamination, pinpoint other sites where it might have spread, and destroy the contaminated drums. The most important after-action finding, however, was that all responses pose unique challenges of their own and provide new lessons to be learned – and implemented through follow-on training.
Additional information and details on this incident and the subsequent response can be found in the New Hampshire 2009 Anthrax Incident After Action Report/Improvement Plan and related exclusive Lessons Learned, available on Lessons Learned Information Sharing (www.llis.dhs.gov)
Jennifer Smither is the outreach and operations manager for Lessons Learned Information Sharing (LLIS.gov), the Department of Homeland Security/Federal Emergency Management Agency’s national online network of lessons learned, best practices, and innovativeeas for the U.S. homeland security and emergency management communities. She received her bachelor’s degree in English from Florida State University.