### **The Face of Terrorism**

#### 

For several months, the Federal Bureau of Investigation (FBI) has been
monitoring the movement of an extremist militia group known as Millenium
Action Group (MAG). The FBI has received information that suggested this
group was planning a series of terrorist attacks in selected U.S.
cities.

![](media/image1.png){width="0.9811023622047244in"
height="1.6299212598425197in"}![](media/image2.png){width="1.4519685039370078in"
height="1.0062992125984251in"}![](media/image3.png){width="1.5374015748031495in"
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height="1.5799212598425196in"}![](media/image6.jpeg){width="1.1429133858267717in"
height="1.4519685039370078in"}

Following a tip from an informant to the Harrisburg Police Department,
the Harrisburg Field Office of the FBI, along with the Bureau's
Hazardous Materials Response Unit (HMRU) conducts a raid on the home of
Ralph Stuart, a laboratory technician at a local biotechnology firm.
Inside his basement they find an array of sophisticated laboratory
equipment, including an assortment of growth media, an industrial dryer
used for pharmaceutical preparation, a centrifuge, a biosafety hood, and
a 100-liter fermenter. Initial swab samples from the equipment returned
no trace of bioweapons agents; however, it appeared that equipment had
been in place for some time.

***What would you know at this time? What information would you share
and with whom would you share it? Do you have adequate plans in place?
What preparatory/precautionary actions would you initiate if any? What
assets are available for potential response? What would you tell the
public?***

> As morning breaks on New York City, the Department of Health (DOH),
> Bureau of Communicable Disease (BCD) begins receiving reports of a
> sharp increase in the numbers of patients presenting flu-like symptoms
> at local institutions. Most of these patients are elderly, younger
> children, or people considered having a compromised health situation
> and who are not responding to therapy with decongestants, analgesics,
> intravenous antibiotics, or antiviral medications. Rapid antigen
> screening tests for the initial patients are negative for influenza.
> Tests for other infectious diseases are ordered.

![](media/image7.png){width="1.7638888888888888in"
height="1.1854166666666666in"}

By mid-day, the Mayor's Office of Emergency Management (MOEM) is
notified of a 25 percent increase in calls to the New York Fire
Department's Bureau of Emergency Medical Services (FDNY/BEMS). Most of
the calls are for severe flu-like symptoms, including body pain,
respiratory distress, and croup. As the day progresses data on the
mounting cases is being collected and analyzed by the DOH and MOEM.
Numerous businesses and city departments are being impacted by personnel
going home sick. The common complaint is having the flu themselves or
needing to assist family member(s) with severe flu. MOEM begins
around-the-clock monitoring of the situation and briefs the Mayor.

> ![](media/image8.png){width="1.7909722222222222in"
> height="2.2694444444444444in"}Though suspicions are growing, patients
> are diagnosed with the flu and prescribed bedrest, fluids, and
> analgesics as needed for fever. Emergency rooms (ERs) across the city
> report a continuing increase in the number of children and elderly
> being brought in with signs of the flu, aches, and asthma-related
> complications. Specimens are drawn for diagnostic testing.
>
> As evening approaches, patients treated earlier in the day are
> returning in full respiratory distress. Others admitted in the morning
> are dying in their beds, and the number of calls to the Medical
> Examiner's (MEs) office is mounting. Post-mortem examinations are
> ordered to determine the cause and rule out foul play.
>
> ![](media/image9.png){width="1.8006944444444444in"
> height="1.0881944444444445in"}The fact that there are not enough
> ambulances to handle the swelling number of requests for assistance
> has been noted by the various news organizations. The 911 Center
> reports that they are near their saturation point with numerous
> requests for assistance.
>
> ![](media/image10.png){width="1.6in"
> height="0.5256944444444445in"}Because of the large numbers of people
> demanding to be seen, several hospitals are requesting assistance from
> the New York Police Department (NYPD) to bolster their beleaguered
> security personnel. Private health clinics and city-run free clinics
> are also inundated with patients reporting flu-like symptoms; the
> clinics are requesting assistance from DOH for what appears to be an
> epidemic.
>
> By nightfall, FDNY/BEMS has received numerous calls reporting sudden
> deaths all over the city. New York hospital managers are hearing from
> colleagues in New Jersey and suburban Connecticut with reports of
> similar, although less numerous, cases.
>
> ![](media/image11.jpeg){width="1.7979166666666666in"
> height="1.4805555555555556in"}Media monitoring the growing crisis
> throughout the day have begun to send crews to the hospitals, DOH, and
> the Mayor's office seeking an explanation. Evening newscasts on all
> three major broadcast networks and CNN lead with reports of an
> unexplained "epidemic" in New York City (NYC). The Mayor's office has
> taken a proactive public information stance to explain the sudden
> increase in illness and associated deaths. Media reports lead to
> anxiety in some citizens who begin to seek medical attention although
> they are asymptomatic.

Hospitals all across the metropolitan area are witnessing a staggering
influx of patients arriving at ERs with signs and symptoms of what
appears to be an unknown flu. Some ER patients are dying while waiting
to be seen. Most patients are not responding to therapy with
decongestants, analgesics, intravenous antibiotics, or antiviral
medications. Rapid antigen screening tests for the initial patients are
negative for influenza. Tests for other infectious diseases are pending.

The number of victims seeking treatment is overloading the health care
system. Hospital estimates provided to the DOH describe as many as
15,000 new cases. The fact that there are not enough ambulances to
handle the swelling number of requests for assistance has been noted by
the various news organizations. The 911 Center reports that they are
near the saturation point with numerous requests for assistance.

![](media/image12.jpeg){width="1.2771653543307087in"
height="1.702755905511811in"}![](media/image13.jpeg){width="1.041732283464567in"
height="0.6354330708661418in"}

The NYC Department of Transportation reports during an MOEM-led
conference call that the morning rush hour was abnormally light, and
transit systems seem to be carrying fewer riders than normal.

> Between the preliminary numbers reported by local hospitals and the ME
> there are more than 5,000 dead. FDNY/BEMS and the NYPD report
> thousands of backlogged calls pending for the removal of deceased
> victims throughout the city, with the largest concentrations in
> Manhattan, Brooklyn, and Queens.

***How would information on this outbreak be tracked? To whom should
this information be communicated and how? At what point would the city's
non-health community be alerted to this situation? What actions can or
should be taken to mitigate this crisis? How can you determine what you
are dealing with? Should a public information strategy be implemented?
If so, by whom? What is the role of public safety personnel in an event
of this nature? What assets exist to supplement the city's resources?
How soon can they respond?***

![](media/image14.jpeg){width="2.1840277777777777in"
height="1.5083333333333333in"}Shortly after midday, several laboratories
in the New York Metropolitan area contact the DOH-BCD about the
isolation of a Bacillus specimen con­sistent with ***Bacillus
anthracis*** from the blood culture of many of the patients with fever
and severe respiratory illness. Aware of the significance of this
discovery, DOH-BCD orders cultures flown to the Centers for Disease
Control and Prevention (CDC) and U.S. Army Medical Research Institute
for Infectious Diseases (USAMRIID) for confirmatory analysis. The NYPD
and FBI Field Office are immediately notified of the preliminary
identification. DOH-BCD immediately launches an epidemiol­ogical
investigation to identify the source of the suspected anthrax outbreak.

> New York City and the nation are facing the horrifying likelihood of
> bioterrorism. Reports from across the city bring the total number of
> what are now suspected to be anthrax cases to nearly 40,000. More than
> 10,000 have already died. Since the collection of data has lagged,
> casualty figures are estimations. Emergency morgues are needed.
>
> ![](media/image1.bmp)Mayor Guiliani convenes an emergency meeting with
> the City Commissioners and representatives from the FBI, the
> Department of Defense (DoD), the Federal Emergency Management Agency
> (FEMA), and the Department of Health Human Services (DHHS). Scientists
> from the USAMRIID present NYC officials with a chilling profile of
> anthrax. The possibility exists that along with the known anthrax
> casualties there may be tens of thousands of other unidentified cases.
>
> Following emergency meetings of the Cabinet and National Security
> Council (NSC), President Clinton declares a national emergency. A
> televised speech assures New York residents and citizens across the
> country that the full resources of the nation have been mobilized to
> care for the victims of the attack and apprehend the perpetrators.
>
> ![](media/image2.png){width="1.3583333333333334in"
> height="1.413888888888889in"}
>
> The White House has directed FEMA and the FBI, in close cooperation
> with the DHHS, to provide assistance to State and local authorities.
>
> Public reaction swells in the aftermath of the President's
> announcement; reactions range from anger to total panic. Tens of
> thousands of city residents flee the city, while thousands more
> converge on city hospitals, clinics, and doctors' offices demanding
> treatment. Routes out of the city are clogged, and key city operations
> managers report massive absenteeism as employees tend to sick family
> members or are themselves affected. Offers of medical assistance pour
> in from nations around the world.
>
> ![](media/image3.png){width="1.7in"
> height="1.4305555555555556in"}Demand is soaring for anthrax vaccine
> and antibiotics, greatly outstripping available supplies. Many people
> are trying to leave the city, causing congestion on the major
> transportation arteries. Depletion of police, fire, and emergency
> medical personnel, as well as most hospital staffs, is hampering the
> response as the effects of the disease are felt throughout the city's
> emergency and medical communities.
>
> A fax is sent to all major news organizations in New York. The
> authors, claiming to be members of MAG, take credit for releasing
> anthrax spores in Manhattan. They issue no demands; instead they warn,
> "We will carry on killing until people understand."

The national and international media are consumed by the story. CNN,
FOX, ABC, NBC, and CBS elect to report details of the terrorist claim.
Electronic and print headlines are unanimous in declaring the attack on
NYC the most horrific act of terrorism in history.

> Offers of medical assistance pour in from nations around the world.
> The shocking impact of the attack rivets the world's attention.
> Security measures in effect in capitals, airports, ports, and at
> critical infrastructure facilities are unprecedented.
>
> ![](media/image4.jpeg){width="1.7166666666666666in"
> height="1.104861111111111in"}The New York metropolitan area death toll
> stands at 46,000. Estimated anthrax cases number 200,000. CDC and
> USAMRIID confirm anthrax from specimens taken from infected patients
> in New York metropolitan area hospitals. CDC notifies State and local
> public health agencies across the country to report any possible
> victims of anthrax that appear in their respective health care
> facilities. Immediate information on the care and treatment of
> anthrax-infected victims is also disseminated as widely as possible to
> health care providers. DHHS and other supporting Federal agencies
> under Emergency Support Function (ESF) #8 (Health and Medical
> Services) of the Federal Response Plan (FRP) assist in information
> dissemination, emergency con­sultation, and dealing with the media. Law
> enforcement agencies are put on alert across the country for the
> possibility of additional terrorist attacks.
>
> The current tally of clinically compatible cases of anthrax is
> 250,000. There have been 75,000 deaths.
>
> The U.S. Public Health Service (USPHS), CDC, and military survey teams
> have found anthrax spore contamination throughout Midtown Manhattan,
> Brooklyn, parts of Queens, and even as far away as Long Island. The
> contaminated areas have been quarantined, and access into and out of
> Manhattan and substantial areas of Brooklyn and Queens has been
> restricted to official traffic.
>
> EPA and DoD (ESF #10) conduct air dispersion modeling to try and
> determine the extent of exposure.
>
> The FBI, with the assistance of the CDC, begins an epidemio­logical
> investigation of the incident to determine possible origin and method
> of dispersion. Disaster Medical Assistance Teams (DMATs), Disaster
> Mortuary Teams (DMORTs), and other Federal assistance continue to
> arrive and provide assistance.

![](media/image5.wmf){width="2.50625in" height="1.261111111111111in"}

> The scale of the disaster dwarfs available resources. Victim care and
> remains removal have overwhelmed city, State, and Federal elements
> responding to the crisis.
>
> DHHS (ESF #8) coordinates procurement and deployment of antibiotics,
> vaccines, medical supplies, and resources with city, State, Department
> of Veterans Affairs (DVA), Food and Drug Administration (FDA), and
> DoD. Drugs and medical supplies are being transported into the New
> York area for distribution to emergency medical facilities. ESF #8
> assigns all transportation coordination to ESF #1 (Transportation) for
> medical supply delivery. Cataloguing and distributing supplies require
> aggressive coordination.
>
> ESF #8 coordinates with ESF #1 and ESF #3 (Civil Works) to restore
> basic services in the affected area and begin removal of the numerous
> dead.
>
> ![](media/image6.wmf){width="2.5722222222222224in"
> height="1.73125in"}People in the downwind zone are presumed to be
> exposed and will require preventative treatment. The number of actual
> cases has continued to skyrocket, although the rate of growth is
> expected to decline. The total estimated victim count now stands at
> 420,000, with 143,000 dead. Several models suggest that the total
> death toll may exceed 400,000 within a week. The economic impact of
> the losses associated with the attack will measure in the hundreds of
> billions of dollars. Elements of the city's infrastructure are
> collapsing, causing disruptions to financial markets and commercial
> activity around the world.

***What are the notification procedures following identification of
Bacillus anthracis (anthrax) as the causative agent? Who is notified? Is
it possible to gauge the scope and magnitude of the attack at this
stage? How will information on anthrax be communicated to citizens,
public safety officials, and throughout the health community? How can
victims of the attack be identified before they show symptoms? How can
the hazard area be determined? What assistance would you request from
the State and Federal governments? What Federal agency(ies) would lead
the Federal response? What assets can the Federal Government immediately
make available? How will the vaccine and antibiotics be delivered,
distributed, prioritized, and administered? How are patients with
ailments unrelated to the current emergency being handled? Are
sufficient resources available to meet their needs? How might this
incident impact other city services?***

> ![](media/image7.wmf){width="1.1152777777777778in" height="1.55625in"}
>
> The full resources of the nation's law enforcement, intelligence, and
> medical investigative agencies have been dedicated to identifying,
> apprehending, and prosecuting the perpetrators.
>
> A number of public facilities across the region have been closed or
> have severely curtailed their hours in the aftermath of the incident.
> Elected officials, religious leaders, and private organizations around
> the globe are leading efforts to muster aid and extend sympathy and
> support.
>
> ![](media/image8.png){width="1.207638888888889in"
> height="1.3in"}Although the economic consequences are being felt
> globally, the local impact is staggering. Every component of the
> public and private sector has experienced debilitating losses.
> Critical private and public sector facilities and valuable resources
> are in or near contaminated areas. Key components of the downtown
> workforce have been decimated. The psychological responses associated
> with a major terrorist event (anger, guilt, horror, etc.) are
> manifest.
>
> City, State, and national leadership---advised by experts in all
> sectors of government, industry, and academia---are attempting to
> define the end state of the incident. One of the most troubling issues
> facing officials is the short- and long-term management of tens of
> thousands of victims.
>
> The FBI is leading a criminal investigation unparalleled in scope and
> urgency. In conjunction with medical personnel and epidemiologists,
> the FBI is gathering evidence and attempting to pinpoint the origin of
> the attack. Anthrax samples are tested at Fort Detrick to type the
> agent to determine its possible source. Physical evidence, interviews
> with victims, and surveillance videos are being collected and
> catalogued as part of the effort to identify the perpetrators.
>
> At an afternoon coordination meeting, Mayor Guiliani and Governor
> Pataki are briefed by Federal officials on plans for continuing
> long-term assistance. Mayor Guiliani wants to approve reduction,
> transfer, or termination of their operations.
>
> EPA, CDC, DoD, FBI, and FEMA, in cooperation with NYC and State
> representatives, meet daily to discuss long-term site remediation. The
> city, region, and nation continue to experience low numbers of cases
> of anthrax from delayed incubation. The city is also concerned about
> hazards from reaerosolization of the agent and has asked for technical
> assistance in long-term hazard analysis and mitigation.
>
> CDC and the Agency for Toxic Substances and Disease Registry (ATSDR)
> are directed to lead a Federal, State, and local program to provide
> continued monitoring of survivors receiving prophylaxis and
> vaccination.
>
> Public observances and memorial services are conducted across the
> nation.

***Who is responsible for cleanup? What biological decontamination
standards exist? How would you track victims? How will the large number
of remains be safely and respectfully handled then disposed? How will
resultant stress be managed for the community and responders? How will
the medical, technical, and law enforcement communities coordinate the
investigation of this attack?***