Introduction

The anthrax attacks of 2001, the outbreak of

severe acute respiratory syndrome (SARS), and

weapons of mass destruction tabletop exercises

have made it clear that no single community can

prepare fully, nor respond completely, to a largescale bioterrorism event. Policymakers recognize

the need to forge relationships and coordinate

preparedness planning efforts at the local, state,

national, and international levels.1 However,

there is little consensus about the optimal level of

localization or regionalization for each of the

resources and services that must be

operationalized during a bioterrorism response. 

We sought to evaluate the evidence regarding

the effectiveness of existing regional systems that

facilitate a response to bioterrorism. We sought

evidence regarding the tasks that would need to

be performed during a bioterrorism response

(such as triage, provision of emergency medical

care, transportation, and surveillance) and

regionalized organizations that would likely

contribute personnel, material, and information

required to perform these bioterrorism response

tasks. 

Methods

Key Questions

The Key Questions addressed in this Report

are:

1. What are the key tasks of local responders—

such as local public health officials, clinicians,

and emergency medical personnel—during a

bioterrorism event? 

2. What resources do local responders require to

perform the tasks identified in Key Question

1?

3. Which existing regional systems for delivery

of goods and services could be relevant to

supplying the resources identified in Key

Question 2? 

4. Can regionalization of bioterrorism

preparedness planning facilitate supplying

needed resources to local responders during a

bioterrorism event?

5. How do geographic variations in the affected

population (e.g., urban as opposed to rural),

special populations, and the interplay of

private and public sector players affect

regionalized systems? 

Literature Searches

We sought relevant articles in four primary

literature sources: the medical, emergency

management, and supply chain management

literatures, and government documents. We

sought articles describing bioterrorism

preparedness plans, vaccination strategies,

evaluations of regionalized health care delivery

systems, case studies of emergency responses,

disaster preparedness plans, evaluations of

responses to disasters, case studies about regional

practices to increase the efficiency of

manufacturing and distribution services,

descriptions and evaluations of government

programs responding to the 2001 anthrax cases,

and bioterrorism-relevant events (e.g., naturally

occurring outbreaks and disasters).

We developed separate search strategies for

each of our four primary literature sources. In

general, for each literature source we searched

databases such as MEDLINE®, indices of key

journals and conference proceedings, and the

Web sites of relevant organizations. At least one

investigator screened titles, abstracts, and articles,

as necessary, to determine if they met inclusion

Evidence Report/Technology Assessment

Number 96

Regionalization of Bioterrorism Preparedness and

Response

Summary

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES • Public Health Service

Agency for Healthcare Research and Quality
2

criteria. From each included article, we abstracted the

following data: information describing the regional system,

methods and results of evaluations of the system, information

about the quality of the study, as well as references in the

bibliography that might meet inclusion criteria.

Methodologies for Evaluating Relevant

Regional Systems

From each of the four literature sources, we sought evaluative

information about:

• Clinical outcomes: morbidity and mortality

• Financial outcomes: costs associated with the event or

responses to it

• Process outcomes: timeliness of the response; adherence to

clinical protocols; measures of cooperation, coordination,

and communication among responders; information about

the incident command structure that was used and how it

affected the regionalized response; and iterative application

of lessons learned from prior bioterrorism-relevant

responses

• Outcomes associated with the efficiency of the bioterrorism

response supply chain including considerations of: the

design of the supply chain network, inventory

management, postponement (which refers to the concept

of customizing a product late in the supply chain),

modularization (which refers to the use of standard parts

that can be used in multiple end products), supply chain

coordination, management of incentives, and management

of information. 

Supplemental Analyses

Because we found no evidence about regionalization of two

key bioterrorism response tasks—bioterrorism surveillance and

the stockpiling of medical supplies required for a bioterrorism

response—we performed simulations of regionalization of these

tasks, using estimates derived from the published literature. In

our surveillance simulation, we explored the tradeoffs in

sensitivity and specificity caused by analyzing surveillance data

locally versus regionally. In our simulation of regionalization of

inventories of bioterrorism-relevant medical supplies, we

evaluated the costs and benefits of differing strategies for preattack stockpiling and post-attack distribution of antibiotics. 

Results

We reviewed 8536 citations, more than 500 websites, 1006

government reports, and numerous texts for potential inclusion

in this Evidence Report. Of these, 396 articles, 61 government

reports, and 75 Web sites met our inclusion criteria. 

Synthesis of the Literature Describing the

Existing Infrastructure for Bioterrorism

Response

We included 22 articles, 25 government reports, and 14

Web sites on systems and organizations with existing

infrastructures likely to contribute to a regionalized

bioterrorism response. This literature describes numerous

systems including, but not limited to, public health

departments at local, state, national, and international levels

(e.g., CDC, World Health Organization); the National Disaster

Medical System (a federally coordinated program that provides

medical and mental health assistance including the evaluation

of patients and provision of hospital care when local capabilities

are overwhelmed); Disaster Medical Assistance Teams

(voluntary specialty medical teams that can be deployed to

provide a wide range of disaster medical services and resources);

the Metropolitan Medical Response System (which expands

municipal bioterrorism preparedness through grants that

provide pharmaceuticals and other supplies and requires

detailed preparedness planning by recipient cities); and the

Department of Homeland Security (which has oversight

responsibilities for many of the key bioterrorism response

agencies and programs such as the Federal Emergency

Management Agency and the Strategic National Stockpile).

This literature suggests that numerous response agencies with

regional organizations could contribute to a bioterrorism

response. However, most of these agencies were designed either

independently or for purposes besides bioterrorism response,

and efforts to coordinate them for bioterrorism preparedness

are only now emerging or under development. 

Synthesis of Supply Chain Case Studies

Relevant to the Bioterrorism Response Supply

Chain

A traditional supply chain is the integrated network of

entities involved in all aspects of the manufacture of goods,

including the procurement of raw materials, their assembly into

the manufactured product, transportation of the product to

distributors, and distribution to final customers.2 The

bioterrorism response supply chain has several related

components: suppliers of raw materials, manufacturers of goods

(e.g., product manufacturers such as drug and device

manufacturers), purchasers, providers who distribute the

products, customers/payors (e.g., the government, employers,

and individuals), and the transportation systems that connect

these components.3 Supply chain management concepts are

directly relevant to those elements of a bioterrorism response

that require the purchase, inventorying, distribution, and rapid

dispensing of supplies. We included 22 articles and one Web

site describing innovations relevant to the bioterrorism supply

chain. From this literature we synthesized four key lessons: 
1. Strategies to improve supply chain network designs,

including regionalization of some elements of the supply

chain (such as pooling of inventories at regional

warehouses), can reduce inventories, improve the capacity

to serve target populations, and save money. Some

bioterrorism response supplies have limited shelf lives, so

minimizing inventory may be important from economic

and logistics perspectives. 

2. Several supply chain case studies demonstrated that

redesigning final products to be assembled from a limited

number of common component parts, even if those

component parts are costly, can result in overall cost

savings for the supply chain (modularization). Similarly,

postponing final customization of end products can reduce

total inventories and costs. For bioterrorism, this supports

the practice used by the Strategic National Stockpile of prepackaging antibiotics and medical supplies for use in

multiple localities, for a variety of bioterrorism events, and

for use by a variety of patient populations. 

3. Coordination of activities of heterogeneous bioterrorism

response supply chain members, with specific consideration

of the incentives of all stakeholders in the supply chain, can

increase efficiency and reduce costs. 

4. For the bioterrorism response supply chain, information

systems that can accurately characterize the available supply

of goods and personnel and the ongoing needs of the

community affected may benefit the response.

Synthesis of the Literature Describing

Responses to the 2001 Anthrax Attacks

We included 30 articles, 14 government reports, and 22

Web sites describing regionalized aspects of the response to the

anthrax bioterrorism of 2001. None of these were evaluations;

rather, most described particular aspects of the response to the

anthrax attacks. From these articles, we synthesized five key

lessons. 

1. Cooperative agreements and regionalized response plans are

needed for effective response to bioterrorism events. Preevent regionalized planning and asset sharing agreements

among local public health agencies and hospitals may

facilitate enhanced surge capacity and coordinate responses

during a bioterrorism event. 

2. Incident command must be well defined and accepted by

all relevant responders. 

3. Information systems for communication among responders

and with the public must be implemented and tested prior

to an event. 

4. The costs and benefits of acquiring, storing, and

maintaining local inventories of medical supplies have not

been established. 

5. The Laboratory Response Network significantly enhanced

regional laboratory surge capacity. Whether the surge

capacity provided by the Laboratory Response Network

will be adequate for a bioterrorism event of larger

magnitude remains untested.

Synthesis of the Literature Describing

Responses to Naturally-Occurring Outbreaks

We included 177 articles, 10 government reports, and 33

Web sites about responses to natural outbreaks including SARS,

pandemic influenza, meningococcal meningitis, smallpox, and

West Nile virus. From our review of this largely descriptive

literature, we synthesized three main lessons regarding a

regional response to outbreaks resulting from bioterrorism. 

1. Communication and cooperation between health

authorities of neighboring regions are needed for adequate

and rapid responses. Rapid communication can be difficult

to achieve through interim agreements. Thus, cooperation

during a bioterrorism response may benefit from pre-event

development and routine use of shared communication

systems. 

2. In the event of a bioterrorism attack, international

cooperation to detect, report, and respond may reduce

associated morbidity or mortality, as it did during the

SARS outbreak.

3. During a bioterrorism event, strategies to protect

responders and their families may be an essential

component of maintaining a robust work force.

Synthesis of the Literature Describing Disaster

Responses 

We included 41 articles, 21 government reports, and 12

Web sites that described regionalized responses to natural or

manmade disasters or described regionalization of disaster

response systems. From these articles, we synthesized three key

lessons, though evaluative evidence is limited. 

1. Information management is essential for assessing the needs

of the local community and the resources available to

them, and for coordinating responses from regional

agencies. 

2. A key component of effective regional responses to disasters

includes mutually agreed upon pre-event protocols that

establish chain of command structures, including plans for

how the chain of command changes as regional and federal

response agencies become involved. 

3. Mutual aid agreements (such as the Master Mutual Aid

agreement in California and the Emergency Management

Assistance Compact in the rest of the United States)4, 5 are

key components in providing surge capacity for regional

response to disasters. These agreements ensure that every

locale does not have to be staffed and prepared for a

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maximal intensity event. They enable risk to be spread

among several locales, and provide cost-sharing of disaster

preparedness. Mutual aid agreements for bioterrorism are

likely to benefit from careful pre-event consideration of

liability issues, remuneration, and licensing. 

Synthesis of the Literature Describing

Regionalization of Trauma Care

We included 80 articles and government reports that

described regionalization of trauma care; 40 of these reported

the results of evaluations of regionalization of trauma care.

From these, we synthesized four key lessons, based on the

evaluative evidence. 

1. Pre-event hospital designation contributes to lower costs

and improved patient outcomes. The evidence from

trauma care regionalization suggests that a key component

of high quality, cost-effective care is limiting high-cost

specialty care to specifically designated hospitals with

increased experience in treating severely injured patients. A

bioterrorism response system may benefit from the preevent designation of hospitals. 

2. Formalized protocols for pre-hospital and hospital care

contribute to improved patient outcomes. A regionalized

bioterrorism response may benefit from similar protocols so

that first responders know where and how to rapidly

transport exposed patients. 

3. An established communication network is essential to the

coordinated regionalization of trauma care. Such a system

could play an important role during a bioterrorism

response. 

4. Correctly aligned incentives, particularly sufficient funding,

are critical to maintaining the participation of designated

trauma hospitals. The included articles suggest that

regionalized trauma care systems do not provide sufficient

incentives for some hospitals to remain in the system. A

bioterrorism response system is likely to benefit from

incentives for hospital participation. 

Synthesis of the Literature Describing

Regionalization of Surveillance for

Bioterrorism

Our search identified 36 articles, two government reports,

and one Web site describing regionalization of surveillance

systems for bioterrorism. From these, we draw four key lessons. 

1. Evaluations of regionalization of surveillance data collection

and analysis are needed. Although numerous syndromic

surveillance efforts in local areas are promising, no study

has evaluated the tradeoffs in terms of costs and benefits of

regionalizing bioterrorism surveillance. 

2. If a regionalized surveillance system uses local data

collection with regional analysis, considerations of means to

reduce costs of data collection and to share relevant

analyses with local data collectors may enhance local

participation. 

3. A common technology platform may facilitate the

collection and analysis of surveillance data. 

4. Privacy issues are a key concern: collection and analysis of

surveillance data need to protect individual privacy while

containing sufficient detail to detect new outbreaks. 

Simulation Model Results

The results of our surveillance model suggest that whereas

large outbreaks can be relatively easy to detect using either

unpooled (i.e., local) or pooled (i.e., regionalized) data analysis

methods, small outbreaks can be difficult to detect by either

method. Additionally, we found that pooling strategies may

improve detection capabilities, but the circumstances under

which pooling strategies are consistently more effective or cost

effective than using unpooled data remain poorly characterized. 

Our inventory logistics simulation model yielded three

results. First, the mortality associated with anthrax bioterrorism

may be highly sensitive to the number of people seeking

prophylactic antibiotics. This is a critical finding given that for

many types of bioterrorism responses it will be difficult to

determine whether an individual has been exposed to the

biothreat agent. Second, strategies that deliver multiple Push

Packs to the site of the attack, until the regional Vendor

Managed Inventory has been delivered to these areas, may

reduce mortality. Finally, increasing the availability of local

inventories may be cost effective only if the annual probability

of attack is high.

Summary of Answers to Key Questions 

Key Question 1: What are the key tasks of local responders

during a bioterrorism event? The literature describes nine main

bioterrorism response task categories: preparedness planning,

field assessment and triage, diagnosis, management of the

acutely ill, prevention of the spread of disease, surveillance,

outbreak investigation, communication, and emergency

management. For each of these main tasks, we considered the

subtasks that responders are required to perform. For example,

subtasks of surveillance include collection, analysis, and

reporting of surveillance data.

Key Question 2: What resources do local responders require to

perform the tasks identified in Key Question 1? For each task

described above, we abstracted information about four broad

categories of resources required for that task: personnel,

material, information, and financial. For example, for the key

task of “prevention of the spread of disease,” numerous

personnel, material and information resources are required,

including: clinicians, public health officials, logisticians and
pharmacists (personnel); pharmaceuticals, isolation facilities,

sites for mass vaccination, and supplies for mass care (material);

prevention guidelines, home-care instructions for patients, and

information regarding characteristics of the infectious agent to

aid decisionmaking about quarantine, isolation, and evacuation

(information); and the financial support for each of these. 

Key Question 3: Which existing regional systems of delivery of

goods and services could be relevant to supplying the resources

identified in Key Question 2? We found numerous systems and

organizations with regionalized infrastructures engaged in the

timely delivery of bioterrorism-relevant material, personnel, and

information. Specifically, we found systems and organizations

responsible for each of the response tasks described in our

answer to Key Question 1: for preparedness planning (e.g., the

Joint Commission on the Accreditation of Healthcare

Organizations), field assessment and triage (e.g., US trauma

care system), diagnosis (e.g., Laboratory Response Network),

management of the acutely ill (e.g. Medicins Sans Frontieres),

prevention of the spread of disease (e.g., Strategic National

Stockpile), surveillance (e.g., Electronic Surveillance System for

the Early Notification of Community-based Epidemics),

outbreak investigation (e.g., Epidemic Intelligence Service),

communication (e.g., ProMed), and emergency management

(e.g., Emergency Management Assistance Compacts). 

Thus, we conclude that numerous existing systems and

organizations could contribute to a regionalized bioterrorism

response. Many of these have long histories of successful

participation in bioterrorism-related events such as infectious

disease outbreaks and natural disasters. However, most of these

systems were designed independently, typically to facilitate

particular response tasks. Ongoing efforts to coordinate such

systems have not been evaluated. 

Key Question 4. Can regionalization of bioterrorism

preparedness planning facilitate supplying needed resources to local

responders during a bioterrorism event?

Our evidence synthesis produced six main results about

regionalization of services for bioterrorism preparedness and

response. 

1. There have been few evaluations of whether regionalization

has benefited a particular response organization or task.

Efforts to develop a regionalized infrastructure for

bioterrorism responses will likely benefit from careful

evaluations of the numerous tasks involved in a

bioterrorism response and the alternative strategies for

providing the necessary resources to perform these tasks.

2. Regionalization has benefited response capability in disaster

situations. Our review of the responses to natural and

manmade disasters found that during large-scale disasters,

local response capacity can be quickly overwhelmed. The

key method of organizing regionalized disaster responses is

by mutual aid agreements. The elements of successful

mutual aid agreements include pre-event ratification of

legislation by all signatories to resolve issues of

compensation, liability, and insurance, and uniform

information systems to track needs and resources.

Bioterrorism responses are likely to benefit from mutual aid

agreements in all states (including agreements with

neighboring regions of Mexico and Canada), which will

provide surge capacity for public health services.

3. Regionalization efforts have successfully expanded surge

capacity for laboratory services. During the anthrax

attacks, the Laboratory Response Network successfully

provided laboratory surge capacity. Whether there is

sufficient transportation infrastructure to facilitate the

delivery of laboratory specimens from a bioterrorism attack

location to Laboratory Response Network facilities during

a larger bioterrorism event has not been evaluated.

4. Information technologies facilitate accurate determination

of response needs and available resources, effective

application of the chain of command, communication

among responders and with the public, and surveillance.

Our review of evaluations of supply chains emphasized the

importance of accurate information for coordination of all

elements of the supply chain. Additionally, the evaluations

demonstrated that investments in information technologies

often resulted in net cost savings for the supply chain while

improving service. The disaster response literature provided

examples of how inadequate information infrastructures led

to delays in responses. Regionalization of bioterrorism

preparedness and response efforts will likely benefit from

careful consideration of the information technologies that

can facilitate sharing of information by different response

organizations and by responders at local and regional levels.

5. The disaster and outbreak response literatures emphasize

that local responders are often at risk of personal injury

during a response. Because local responders will be the

first on a scene during an emergency, bioterrorism

responses may benefit from careful consideration of the

incentives of local personnel to participate in a response

and from first responder training that emphasizes personal

safety, triage, diagnosis, and outbreak management tasks. 

6. Few included articles specifically articulated lessons learned

from their bioterrorism-related preparedness or response

experiences. Our review of government documents,

particularly responses of military personnel, found that

organizational commitment is a key factor in implementing

a ‘lessons learned’ approach to ensuring that knowledge

gained from both good and bad experiences is maintained

in institutional memory. Plans to regionalize services for a

response to a large-scale bioterrorism event could benefit

from the experiences of responses to small bioterrorism

events and relevant naturally occurring outbreaks if the

lessons learned from these experiences were documented

and used to improve planning efforts. Given the

complexity of a bioterrorism response, the iterative

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application of lessons learned from one experience to the

next requires commitment from all relevant response

organizations to institutionalize a ‘lessons learned’

approach.

Key Question 5: How do geographic variations in the affected

population, special populations, and the interplay of private and

public sector players affect regionalized systems? In the United

States, special populations including children, the elderly, the

disabled, and pregnant women account for about 134 million

people.6-9 Thus, bioterrorism preparedness planning requires

consideration of these special populations. However, we found

little evidence that specifically addressed variations in

regionalized responses on the basis of geography, population, or

public-private cooperation. 

Discussion

Given the complexity and cost of training, staffing,

equipping, and mobilizing an adequate bioterrorism response

infrastructure, no single community can be expected to develop

and maintain the necessary capacity for a large-scale

bioterrorism response. Instead, regionalization may benefit

some bioterrorism preparedness and response capabilities. Our

extensive search of four literature sources relevant to

bioterrorism responses found that the response infrastructure

for a bioterrorism event includes numerous agencies with

regionalized organizational structures. However, most of these

agencies have been developed independently or for purposes

other than bioterrorism response, and efforts to coordinate

them for bioterrorism preparedness are underway but not yet

widespread. Specifically, the Department of Homeland

Security, which has oversight and coordination responsibilities

for many of the agencies that would contribute to regionalized

bioterrorism responses, is currently reorganizing its regional

structure.

We conclude that regionalization is likely to benefit elements

of a bioterrorism response including the provision of surge

capacity in essential response services such as triage, the

provision of medical care, distribution and dispensing of

prophylactic therapies, outbreak investigation, security

management, and emergency management. Additionally,

regionalization may be a cost effective strategy for developing

teams of trained response personnel and maintaining

inventories of response equipment. Numerous response

organizations with regionalized infrastructures will serve key

functions during a large-scale bioterrorism response.

Coordination of these organizations may benefit from

implementation of information management strategies and preevent agreements that specify response roles, remuneration, and

chain of command.

Future Research

Despite the large number of studies and articles we reviewed,

we found very few evaluations of systems relevant to

bioterrorism preparedness, and even fewer evaluations of the

regionalization of a system relevant to bioterrorism

preparedness. Future research is needed to fill this gap in the

literature. Specifically, evaluations are needed for a better

understanding of the costs and benefits of regionalization of

surveillance, inventory management and distribution systems,

and information management.

Availability of the Full Report

The full Evidence Report from which this summary was

taken was prepared for the Agency for Healthcare Research and

Quality (AHRQ) by the Stanford–UCSF Evidence-based

Practice Center under Contract No. 290-02-0017. Printed

copies may be obtained free of charge from the AHRQ

Publications Clearinghouse by calling 800-358-9295.

Requesters should ask for Evidence Report/Technology

Assessment No. 96, Regionalization of Bioterrorism Preparedness

and Response. Additionally, the report and this summary will be

available online through AHRQ’s Web site at www.ahrq.gov. 

Suggested Citation

Bravata DM, McDonald KM, Owens DK, Wilhelm ER,

Brandeau ML, Zaric GS, Holty JEC, Liu H, Sundaram V.

Regionalization of Bioterrorism Preparedness and Response.

Summary, Evidence Report/Technology Assessment No. 96.

(Prepared by Stanford–University of California San Francisco

Evidence-based Practice Center.) AHRQ Publication No. 04-

E016-1. Rockville, MD: Agency for Healthcare Research and

Quality. April 2004.

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www.ahrq.gov

AHRQ Pub. No. 04-E016-1

April 2004

ISSN 1530-440X