Implications Drawn from a Military Bioterror Exercise in Israel

Abstract

Orange Flame is an Israeli preparedness build-up project, conducted by the Ministry of Health, that is aimed at improving national readiness and preparedness for unusual biological events. The project is intended for both medical and nonmedical organizations, and, since 2011, the exercise has also included operational units outside the medical corps. This has provided valuable insights into the consequences of bioterror or naturally occurring outbreaks for operative functionality and for the unique medical, logistical, and administrative efforts required from the armed forces in such an event. The 2-day drill reported on here executed a notional scenario in which category A bioterror agents were dispersed, causing civil and military casualties. Military personnel observed and assessed the performances of all participating organizations and observed the employment of emergency protocols during the drill. Military sustainment and operative capabilities were significantly affected by the occurrence of an unusual biological event. Comprehensive actions to be executed during such a scenario included quarantining military bases, considering postponement of military operations, and transferring on-call missions to other bases. Logistic consequences included the need for manpower and equipment reinforcement, as well as food and water supplies in cases of suspected source contamination. The project unveiled many operational and logistic quandaries and exposed various potential effects of a bioterror attack in the military. Lessons learned were used to revise preevent national and military doctrine for unusual biological events.

The authors report on Orange Flame, a 2-day drill conducted by the Ministry of Health aimed at improving national readiness and preparedness for unusual biological events. The project unveiled many operational and logistic quandaries and exposed various potential effects of a bioterror attack in the military. Lessons learned were used to revise preevent national and military doctrine for unusual biological events.

The deployment of biological weapons can exhibit different forms and shapes, ranging from the contamination of water sources and animal infection to the dispersal of aerosolized microorganisms. In addition to the anticipated effects on the medical and veterinary establishments, an unusual biological event (UBE) has a complex psychological impact as it spreads fear and anxiety among the population; this was recently seen in the current Ebola virus disease outbreak in West Africa.¹ Such an event could also have an economic impact and environmental effects. These implications obligate government organizations, military forces, medical personnel, and public health officials to prepare and practice a coordinated plan of response.^2-6

Orange Flame is a capability-building project, led by the Ministry of Health and the Home Front Command, which is subordinate to the Israel Defense Forces (IDF). The Orange Flame project is designed to prepare civilian, military, medical, and nonmedical organizations to appropriately respond in a case of an unusual biological event. The Orange Flame project provides a platform by which generic pre-written contingency plans and procedures can be tested and revised. It also challenges the coordination between the various organizations involved in the management of an unusual biological event.

A plethora of civil organizations participates in Orange Flame, including hospitals, emergency medical services, regional health authorities, the Israel Center for Disease Control, health maintenance organizations (HMOs), the Ministry of Health, public health services, the Israeli Epidemic Management Team (EMT), national reference laboratories, local municipalities, and the National Emergency Management Authority.^7-9 Representatives of the various organizations are gathered at the Ministry of Health war room to ensure the flow of information between organizations. When the implications of the situation can jeopardize national security, the Ministry of Defense takes responsibility for and command over the situation.

A “real-life” exercise is executed once a year, each time in a different district of the country. The scenario remains confidential until the simulated discovery of an unusual morbidity on the morning of the first day. Thus far the drills have dealt with man-made bioterror attacks, although response elements are also similar in cases of naturally occurring outbreaks.

The Orange Flame 6 drill (OF-6), which was executed in 2011, extended IDF participation to include combat forces, as well as operations and logistic headquarters.¹⁰ The extensive nonmedical military involvement in OF-6 provided unforeseen insights into the predicted effect of an unusual biological event on the military. It also enabled analyses of operational performance and containment during an outbreak and challenged the coordination and collaboration between the IDF and civil emergency organizations. Above all, OF-6 was designed to test the ability to maintain operational competence during an unusual biological event.

The following overview delineates the implications of an unusual biological event on military units. Specifically, it illustrates the complexities and lessons learned from national drills regarding unit functionality and mission sustainment.

Military Corps Role in Preparation

The emergency response system in Israel is characterized by a pronounced symbiotic collaboration between military and civilian organizations. While all hospitals in Israel are civilian, they provide care for military personnel as well. Correspondingly, the Hospital Contingency Branch in the Home Front Command acts on behalf of the Ministry of Health emergency division to prepare all general hospitals for mass casualty events, including chemical, biological, radiological, and nuclear scenarios. In every crisis, there is a built-in mechanism of reciprocal exchange of information and cooperative measures between the 2 bodies.^6,7-10 The Home Front Command medical war room serves as the coordinator.

The health system doctrines on the management of CDC's category A agents¹¹ were written and revised by the national Epidemic Management Team. The Epidemic Management Team is a multidisciplinary experts group, established to advise the director general of the Ministry of Health on outbreak prevention, contingency measures, and measures to be taken in case of an epidemic or unusual biological event.⁷ The IDF Medical Corps and Home Front Command representatives are also members of the Epidemic Management Team.

Contingency plans have been developed in the military.⁸ Such plans include clinical guidelines for military medical personnel, standing orders for the field medical unit or clinic, protective equipment guidelines, infectious patient movement procedures, medical headquarters actions, and a military plan for postexposure prophylaxis deployment.

Orange Flame in the IDF

Orange Flame is a preparedness build-up project that serves to train medical and nonmedical staff at 3 levels: tactical, operational, and strategic. The tactical level includes the individuals and the units. The objectives of the tactical level include identification, early management, infection control, decontamination, epidemiologic investigation, and local containment of the outbreak.¹²

One of the critical challenges in an outbreak is the early detection of unusual morbidity. This challenge is accentuated in a bioterror attack scenario, which could potentially utilize nonendemic and unfamiliar biological agents. Primary care physicians must be familiarized with the clinical presentation of unusual biological threats and be competent in the initial management of an unusual biological event. Such expertise is especially important in a military setting, where consultants and laboratory services are limited. Medical doctrines and educational materials are readily accessible to medical personnel via military online services.¹⁰

Each unit is individually trained to establish its own contingency plan and standard operating procedures. The decision to activate the plan could be taken at the unit level or superimposed by the headquarters.

The operational level is involved with the initial response of any of the organizations mentioned above. Each organization practices its own contingency plan, while learning to communicate and cooperate with the other organizations involved. One example is the collaborative epidemiologic investigation between the Military Public Health Services and the Ministry of Health. Sharing information between Civil and Military Public Health Services facilitates the investigation and establishment of the exact place and time of the biological agent dispersal.

The strategic level deals with strategic elements: The military Epidemic Management Team advises the Surgeon General in cases in which operational endurance is compromised.¹³ The Military Public Health branch guides the military's medical response. Military–civilian interrelations are challenged in cases in which the military is required to operate in a civilian environment, such as imposing quarantine on civilians by IDF servicemen, maintaining public order, or even distributing chemoprophylaxis. For example, a civilian point of dispensing (POD) could be deployed by Home Front Command soldiers on behalf of the Ministry of Health. Only the Ministry of Defense is allowed to employ the military to assist civilians.

Methods

The OF-6 national drill was held in the northern district of Israel for 2 days and included more than 1,000 participants. The scenario involved the dispersal of 2 category A bioterror agents: Botulinum neurotoxin (BoNT) and Bacillus anthracis bacteria. A regional brigade and an air force base, including their medical staff, commanding officers, and operational constituents, took part in the exercise. On the second day, a military POD was deployed to distribute postexposure prophylaxis.¹⁴ Other military participants included the Northern Command Headquarters and the General Staff Headquarters. The Identification and Burial Branch and the military Epidemic Management Team were also involved.

Military evaluators underwent briefing and assessed numerous facets of the drill using an adjusted checklist and a prewritten questionnaire, which included the proper implementation of doctrines, commands, and SOPs. Communication between organizations and along the chain-of-command, infection control in the affected units, and the operational response to the emergency situation were also evaluated. Participants were later debriefed and asked to summarize their experiences.

Conclusions were drawn from observer reports, war room logs, assessment reports, and participant debriefings. Finally, a summary of participant experiences was prepared at the end of the drill.

Drill Scenario and Implications

On November 21 a terrorist arrived in Israel by civilian flight. Four days later he deployed anthrax dispersal devices in a shopping mall and in the fields of a rural settlement near an air force base. The anthrax spores contaminated these places, including family housing in the air base. A second terrorist, who worked in a salad factory, scattered material containing BoNT in vegetables marketed regularly to numerous institutions including hotels, restaurants, and army units. The drill began on November 30 with the detection of the unusual morbidity among patients arriving at civil and military clinics.

Detection Phase

On the morning of November 30, a sham airman arrived at the air base clinic. Initial assessment revealed fever, cough, shortness of breath, and nuchal rigidity. Meningitis was suspected, and the clinic's staff was ordered to wear N-95 respirators. The patient remained isolated in the examination room. The public health officer instructed that the patient be evacuated to the nearest hospital while wearing a surgical mask and that an initial epidemiologic investigation be conducted to identify all contacts.

Shortly afterward, the patient's wife and son arrived at the clinic with similar symptoms. The wife, a teacher in a kindergarten located on the military base, reported that she had been at work the day before when she was already sick. A report regarding the suspected case of meningitis and afflicted family was delivered to the base's war room, the air force medical headquarters, and the air force headquarters. The public health officer was also notified. The wife and son were evacuated to the hospital by ambulance staff protected with gloves, coveralls, face shields, and N-95 respirators while using a negative pressure cabinet transfer system.

Meanwhile, 2 more airmen reported to the clinic with similar symptoms to those of the aforementioned family. At that stage, the recognition of unusual morbidity, rather than just coincidental infectious disease was made. Medical staff were instructed to wear full personal protective gear against contact, droplet, and airborne transmission. Personal details were taken from the clinic's staff and visitors who had been potentially exposed. A staff member was appointed to monitor staff health. The clinic's commanding officer was instructed to prepare a list of all children and staff who had been in contact with the sick teacher. Kindergarten teachers were asked to stay vigilant for any disease symptoms among the kindergarten children and staff.

Later that day, the base received a report regarding the death of another airman, serving at the same base, who had been hospitalized a few days prior with similar symptoms. The Identification and Burial Branch personnel took care of the cadaver wearing full personal protective equipment (PPE) against contact, droplet, and airborne transmission, assuming that the cause of death was related to the same still-unknown agent. The training included handling the deceased according to a prewritten protocol and the relocation of the body to a military morgue for identification, without carrying out an autopsy. After identification, the body was put into an airtight coffin in accordance with protocol.

Outbreak Clinic Phase

Two hours after the arrival of the first patient, the interim clinical case definition was distributed. The clinic's staff was instructed to function in an outbreak-clinic mode. This entailed preparation for the arrival of additional suspected cases while maintaining routine clinic activities. The outbreak-clinic had 2 distinct zones, one of which was designated for suspected cases. People working in this space had to wear full PPE. The other space was designated for routine activities, and no special measures were taken in that area. A staff member wearing PPE conducted the triage at the clinic's entrance. Those who met the interim case definition were instructed to wear a surgical mask and proceed to the “outbreak zone,” while those who did not meet the interim case definition were directed to the “routine zone.” The areas were clearly marked and had separate entrances and exits, thus enabling one-way traffic of patients. During the drill, the staff managed 30 patients with various symptoms. After initial evaluation and treatment, all those who met the case definition were transferred to hospital.

As the exercise advanced, additional clinical presentations that did not meeting the interim clinical case definition were recognized. These patients presented with blurred vision, difficulty in swallowing, and signs of descending paralysis. Following the report of the newly discovered morbidity cases, the case definition was updated. These patients were transferred to hospital as well.

Containment Measures

As the number of patients increased, the squadron base commander became more involved. Orders regarding the containment of the outbreak were issued following the advice of the medical officer. At that stage, the route of exposure was unclear, so meticulous measures were taken. The base was put under quarantine. Movement into and out of the base was prohibited. Areas suspected to be contaminated were mapped and closed. A protected firefighter team was instructed to inspect family housing and kindergartens in the search for additional ill individuals. A manpower list was prepared containing all individuals currently posted at the base, alongside all those who had been in proximity to the base within the past 48 hours prior to the initial outbreak. Officers were instructed to search for and direct every airman who met the case definition to the clinic. Ill airmen outside the base were instructed to go to civilian hospitals and notify the medical staff that their place of service was involved in the outbreak.

Members of all units were instructed to avoid drinking tap water until the source of the contamination was identified. Air conditioning was shut down, and people were instructed to avoid gathering. Military police were requested to set up barricades in order to limit access to the base, and N-95 respirators were made readily available.

Operational activity was reduced to the absolutely necessary. Routine alert missions were forwarded to other bases. A designated area at the base was mapped to enable operational continuity at a location that was as safe as possible.

At a later stage of the drill, an additional assessment of the situation was made. It included a revised case definition, reports of other clinical cases in proximity to the base, and animal mortality. All emergency orders mentioned were reinforced. An urgent request for reinforcements was launched to the air force medical headquarters. The request included medical staff, mental health specialists, and both medical and logistic equipment. The needs for a public health specialist and Home Front Command representatives for joint evaluation of the situation were expressed as well.

The air force base war room instructed high-ranking officers to avoid gathering and to assign trained surrogates. The clinic's staff was asked to distribute leaflets regarding the situation, brief commanders, and instruct the base population about infection control and the need for prophylaxis treatment.

Headquarters Directives

Information gathered from the military and civilian medical services led to the clear deduction of an unusual morbidity situation. Accordingly, military public health branch officials instructed the relevant military clinics to function in an outbreak mode. A “suspected unusual biological event” was declared, and the SOP for such an event was executed.

The medical corps headquarters distributed information to the medical personnel on the scene, including a clinical case definition, clinical guidelines, and information. Recommendations for water consumption and additional instructions for commanders and servicemen at all units were given. The Home Front Command was requested to communicate about the situation among the general population, including the number of cases and hospital occupancy.

Containment measures included the implementation of quarantine in all military bases. Activity was reduced to the bare necessities. Senior officers were instructed to evaluate their operational assets and to be prepared for the execution of prewritten commands regarding the unit's SOP following a bioterror event. On-call missions were abbreviated to ensure shorter response periods. All units were instructed to deliver reports on human resources and equipment requirements.

Later that day, the clinical case definition was updated to include 2 clinical syndromes: (1) a respiratory syndrome consisting of fever and respiratory symptoms, with or without clinical meningitis (Bacillus anthracis infection symptoms), and (2) neurologic syndromes devoid of fever (botulism symptoms).

By noon, a confirmatory diagnosis of anthrax infection was made. In the early afternoon, the diagnosis of anthrax and BoNT was affirmed. The anthrax dispersal mechanisms were located and removed. The source of BoNT was suspected to be a line of industrialized salads. Revised infection control instructions were distributed. The level of protection was reduced to standard precautions and all industrialized salads were banned for consumption.

The military Epidemic Management Team recommended a prophylactic treatment against anthrax for all servicemen and civilians who might have been exposed to the bacillus spores. The treatment was supplied on the second day of the drill at the military POD and included the administration of a vaccine and antibiotics.

Once a contagious source was excluded and preliminary findings from the ground were taken and analyzed, the military Epidemic Management Team recommended lifting the quarantine in military bases. Based on risk analysis assessments, they also instructed limited decontamination of the runway and surroundings. Routine flights and operational activity were resumed in areas where reaerosolization was not considered a threat. Guidance on contaminated food disposal and handling of the clothes was given.

Discussion

The Ebola virus disease and Middle East respiratory syndrome-corona virus (MERS-CoV) epidemics emphasized that unusual biological events can occur anytime and anywhere without prior notice. Failure to contain an epidemic can have devastating effects.^15,16 Israel's relatively small territory is characterized by numerous army bases located in relative proximity to nearby communities across the state. This requires coordination, information sharing, and joint efforts to contain an outbreak. The close relationship between Israeli military and civilian emergency systems, which is mainly achieved by the involvement of the Home Front Command and its representatives in the Ministry of Health, allows coordinated and cooperative response in cases of biological crisis. Furthermore, collective and corresponding activities are needed. As opposed to deployed units, this proximity enables samples to reach the laboratory within 2 to 3 hours after being taken, thus saving the need for designated laboratory services in the field. It also mandates military and civilian teams to carry out a joint epidemiologic investigation

Many articles have described medical preparedness for a bioterror event.^6-10,17-19 It is well recognized that the impacts of an unusual biological event go well beyond the health system alone. While some articles deal with either civilian or military planning for such an event, others describe policies, and a few delineate inferences drawn from drills or tabletop exercises in order to assess national crisis and consequence management capacity.

The Orange Flame project uncovered several issues that might otherwise have gone unnoticed. Conclusions were drawn and new perspectives involving military preparedness and operative capabilities in time of an outbreak have been developed. Among them are the following:
1. Operational dilemmas: A major bioterror attack on the military invokes the implementation of base quarantines, delay of operational missions, exchange of on-call missions, and social distancing within military units. Manpower shortages can be expected due to the quarantines and morbidity. Missions may have to be deferred because of the absence or redirection of essential officials. Consequently, designated substitutes should be assigned to high-ranking officers and essential positions. War room and security forces staffing should also include standby officials.

2. The important role of an epidemiologic investigation team: An early epidemiologic investigation is vital. Effective interrogation must integrate military and civilian public health professionals, and data must be pooled together. Early establishment of the place and time of biological agent dispersal allows early intervention, containment, and early prophylaxis treatment. The resulting deductions also carry operational implications and should be delivered to the combat and logistic officers as soon as possible. In the exercise, the delay in the epidemiologic investigation results was partially due to the absence of a computerized database. Clinical and epidemiologic data were handwritten, thus complicating data analysis and ultimately hindering the appropriate response.

3. The critical role of a military epidemic management team: The need for the military epidemic management team to act as a distinct consulting body for the surgeon general is imperative for sustaining operations. A good example is the risk of anthrax reaerosolization after the removal of the dispersal devices. The decision was based on environmental sampling, meteorological data, and operational needs. The conclusion that the risk of reaerosolization was low enabled routine and combat capabilities to be restored.

4. Logistics significance: The scenario staged logistic challenges with increased demands for supplementary medical and mental health personnel, equipment, and clean food and water supplies due to suspected resource contamination. An effective quarantine also bears logistic implications.

5. The importance of infection control: Infection control includes the adherence of personnel to predesignated roles in accordance with the clinics' contingency plans. Such activity is vital for the containment of an outbreak while maintaining the safety of medical personnel. Of course, this lesson is not unique to the military, but it must be emphasized and controlled, especially in places where the medical services largely rely on reservists, who may not be fully familiar with the plans.^18-20 In the military setting, medical staff morbidity is even more problematic, when substitutes may not be readily available.

6. Mortuary in an outbreak: Treatment and burial must be conducted in convergence with the military identification and burial branch, whose participation in the drill unveiled a few technical issues: (1) the need for demarcated burial locations, (2) the inability to carry out the full identification process of cadavers infected with highly contagious organisms, and (3) the need for logistic equipment and PPE for burial.²¹ The risk of disease transmission by cadavers is well recognized.²² Autopsies of people who died during an unusual biological event expose staff to unwarranted risk. In these cases, auotopsies should be done with full protective PPE in designated morgues only and only after considering their necessity. In general, after the first index cases, autopsies should not be performed except under special circumstances. These recommendations are in line with the acceptable guidelines for handling Ebola virus disease cadavers.²³ Although these lessons are not unique, in the military setting there is a special need for accommodation with mortuary affairs procedures and protocols.

7. Military information center: Unusual biological events trigger anxiety and questions among soldiers as well as commanders.^24,25 The questions asked and the answers given are different from those in the civilian system. Therefore, there is a need for a distinct military call center to provide quick and effective responses to callers. While working with commanders, a proactive approach is needed. Unlike the community, formal leadership is easily identified within the military. Information and data should be delivered to commanders. This will guarantee full adherence to guidelines.

8. Setting a military POD for military personnel: It should be considered that the military is able to independently open a POD to provide prophylactic treatment. Its location on the military base enables a more rapid return to routine activity and better control of compliance, with minimal loss of work time, thus reducing the effect on operational continuity. The mode of action and formation of the center should be based on civil doctrine and must be tailored specifically to military clinics.²⁶

Drill Constraints

It is important to note a number of observed limitations pertaining to the military elements in the Orange Flame drill. The primary constraints of the drill lay within the brief 1-day training of staff in clinics and the relatively late distribution of guidance from the national Epidemic Management Team and Military Public Health Branch. This has led to the independent management of such events by clinic staff and base commanders, emphasizing familiarity with prewritten contingency plans.

Orange Flame is defined as a capability-building project aimed at improving civil and military organizations' preparedness for an unusual biological event. We could not draw conclusions regarding knowledge retention and organizational competence over time.

Nevertheless, we are under the impression that the Orange Flame project increased the national ability to deal with an unusual biological event. The OF-6 demonstrated the importance of readiness and preparedness among nonmedical elements in the military. Functional and operational capabilities were preserved despite the outbreak. New dilemmas were identified and attended to by the military Epidemic Management Team. The presence of prewritten policies and contingency plans regarding the management of different biological agent outbreaks has proven to be of utmost importance, providing a platform for civilian and military response.

Conclusions

The Orange Flame project provided invaluable insights regarding the expected impact of a biological outbreak on military operative function. Lessons were implemented in the revised plans, and Orange Flame has proven to be a useful model for the enhancement of preparation for such an event among civilian and military organizations. The exercise revealed the unique implications of unusual biological events on the operational system. These effects can be mitigated with proper preparation and response planning.

Footnotes

Acknowledgments

The authors wish to acknowledge Anat Zurel-Farber, Michal Ya'acobi, and Eran Alon for their support and participation in the execution of OF-6 in the medical corps.

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