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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program 1 Introduction In the wake of several major acts of terrorism in the early 1990s, some within the United States itself (the bombing of the Alfred P. Murrah Federal Building in Oklahoma City in 1995 and the World Trade Center bombing in 1993) and some in other countries (the release of nerve gas in the Tokyo subway in 1995), the U.S. federal government dramatically increased funding to combat terrorism. According to the Office of Management and Budget (2001), even before the awful events of September 11, 2001, more than $9.6 billion of the fiscal year 2001 federal budget was designated for such programs, including more than $1.7 billion for actions directed against terrorism with weapons of mass destruction (WMD), that is, nuclear weapons and chemical, biological, and radiological (CBR) agents. (The expenses incurred in responding to the results of the airliner hijackings on September 11, 2001, and to the effects of the mailing of the anthrax spore-laden letters that followed will undoubtedly add substantially to those totals when a full accounting is available.) Among these federal efforts to combat terrorism with WMD is the Metropolitan Medical Response System (MMRS) program of the U.S. Department of Health and Human Services (DHHS), which attempts to enhance the preparedness of major U.S. cities to handle the health and medical consequences of an attack or threatened attack with CBR agents. That program is the subject of this report.
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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program CHEMICAL, BIOLOGICAL, AND RADIOLOGICAL TERRORISM CBR agents have become a focus of counterterrorism efforts because they possess a number of characteristics that would seem to make them attractive to terrorists. Dispersed via the air-handling system of a large public building, for example, a very small quantity of a CBR agent may produce as many casualties as a large truck full of conventional explosives, making the acquisition, storage, and transport of a powerful weapon much more feasible. Although not as easy to acquire or make as some have suggested, serviceable CBR weapons are within the intellectual, financial, and technological reach of many groups and individuals. Some CBR agents can be delivered very effectively as “invisible killers,” that is, as colorless, odorless, and tasteless aerosols or gases, enhancing their psychological impacts and making it difficult to locate and identify the source. Some if not all CBR agents are also long-lasting threats. That is, contaminated victims of attacks with chemical, radiological, and some biological agents can spread the agent to others far from the scene of the initial release, and some infectious biological agents will ultimately transform the victims into carriers who can transmit the agent themselves. Lastly, the biological and radiological agents and some of the chemical agents of concern produce their deleterious effects only after delays of hours to days or weeks after exposure, facilitating the escape of the perpetrator and making detection of the attack difficult for both healthcare providers and law enforcement officials. Chemical Agents There are thousands of chemicals that at some dose may result in morbidity or mortality for humans. In the present context, “chemical agents” generally comprise a relatively short list of chemicals that at some time have been “weaponized” for military use. Some of these agents have no nonmilitary use (e.g., nerve agents and mustard gas); other agents such as chlorine and ammonia are widely used by industry. These agents are often classified by the site or nature of their effects in humans, such as nerve agents, blister agents, choking agents, vomiting agents, incapacitants, and tear agents; and many of these agents are not well known by civilian hazardous materials technicians and other emergency responders, medical personnel, or law enforcement officials. Even common industrial chemicals may be difficult to identify without specialized equipment when they are encountered in an unfamiliar context. The agents in Table 1-1 have been the primary focus of efforts to prepare for chemical terrorism, in part because of their toxicities but to a greater extent because of the health care community’s unfamiliarity with these agents.
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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program TABLE 1-1 Chemical Agents and Their Effects Agent Effects Onset First Aid Agent Effects Onset First Aid Nerve agents: tabun (GA), sarin (GB) soman (GD), GF, VX Miosis, rhinorrhea, dyspnea, convulsions Seconds to minutes Decontamination, atropine, pralidoxime, ventilation, anticonvulsants Vesicants (blister agents): mustard (H, HD), Lewisite (L), phosgene oxime (CX) Erythema, blisters, eye irritation, blindness, dyspnea, coughing Minutes to hours Decontamination, topical antibiotics, bronchodilators, ventilation, British anti-Lewisite Blood agents: hydrocyanic acid (AC), cyanogen chloride (CK), arsine, methyl isocyanate Panting, convulsions, loss of consciousness, apnea Minutes Nitrites, sodium thiosulfate Choking agents: phosgene (CG, DP), chlorine, ammonia Tightness in the chest, coughing, dyspnea Minutes to hours Oxygen, bronchodilators, ventilation SOURCE: Sidell et al. (1997). Figure 1-1, taken from an earlier Institute of Medicine (IOM) publication (Institute of Medicine, 1999), illustrates in a very elementary way some of the actions required to cope with a chemical agent incident such as the one that took place in the Tokyo subway in 1995. Biological Agents Biological agents with adverse effects on human health include viruses, bacteria, fungi, and toxins. Specific toxins are included here rather than under chemical agents only because they are chemicals produced by a living entity (ricin from castor beans, saxitoxin from certain shellfish, and botulinum toxin from the bacterium Clostridium botulinum, for example). The distinguishing feature of biological agents other than toxins is their ability to propagate: exposure to an extremely small amount can lead to an overwhelming infection, and the victim may even become a source of infection for additional victims. This propagation within the exposed person (that is, incubation) takes time, however. The effects of viruses, bacteria, and fungi may not become apparent until days or weeks
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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program FIGURE 1-1 Flow chart of probable actions in a chemical or overt biological agent incident. EMS, emergency medical services; decon, decontamination. Source: Institute of Medicine (1999).
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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program after the initial exposure, so there may be no obvious temporal or geographical concentration of victims to help medical personnel arrive at a diagnosis and make law enforcement personnel suspect a crime. Diagnosis of the illness in individual patients will also be rendered more difficult because most of the agents considered to be likely threats are very rarely seen in U.S. cities and the initial symptoms that they produce (fever, headache, general malaise) are also characteristic of those produced by many common diseases. As difficult as it was to contain the spread of anthrax spores from just a few spore-filled letters in the autumn of 2001, the fact that the letters announced the presence of anthrax spores actually made the diagnosis and response far easier than if, for example, the perpetrator had covertly introduced spores into the air-handling system of a sports arena or airport. The victims in that case would have dispersed, perhaps very widely, by the time they became ill, and many might have died before an accurate diagnosis could have been made. Figure 1-2, from a previous IOM report (Institute of Medicine, 1999), illustrates some of the actions required to cope with the effects of a covert attack with a biological agent. As in the case of chemicals, would-be terrorists have a very large number of potentially harmful biological agents from which to chose. Indeed, the tools of biotechnology might even be used to make some biological variants that have not previously existed, so to suggest that would-be terrorists will only use agents that have been the focus of military weapons programs would be folly. The agents that have been developed as biological weapons were carefully selected for their suitability as weapons, however, and few American physicians have experience in either the diagnosis or treatment of the diseases caused by those agents. For that reason, these agents have been the focus of counterterrorism training and other preparations. The specific agents that MMRS program cities are asked to consider in their planning are presented in Table 1-2 along with information on characteristics of the associated disease and on prophylaxis and treatment regimens currently recommended by the Centers for Disease Control and Prevention (CDC) and the U.S. Army Research Institute of Infectious Diseases.. Radiological Agents The term “radiological weapon,” in distinction to the term “nuclear weapon,” refers to a weapon that would disseminate radioactive materials by means other than an uncontrolled fission chain reaction. The so-called dirty bomb, which consists of radioactive material wrapped around conventional explosives, is the best-known example. Nuclear power plants are the largest nonmilitary users of radioactive materials, but small
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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program FIGURE 1-2 Flow chart of probable actions in a covert biological agent incident. HMO, health maintenance organization. Source: Institute of Medicine (1999). quantities of radioactive materials are used in a variety of medical procedures at hundreds of locations throughout the United States. The radiation emitted in the decay of radioactive materials, as well as cosmic rays and conventional X rays, is called “ionizing radiation” because the radiation strips electrons from atoms and molecules that it encounters, including those in human tissue. Exposure to excessive amounts of ionizing radiation does not make one radioactive; but in the short run it can produce skin reddening and loss of hair, nausea and vomiting, diarrhea, sterility, tissue fibrosis, organ atrophy, bone marrow failure, and death. None of these effects are instantaneous, so radiological terrorism would present some of the same challenges for clinical diagnosis and law enforcement that covert bioterrorism would. Some of these effects may be temporary, but the genes of some exposed individuals may also be damaged, leading to cancer or birth defects in their offspring that are manifest only years later. No treatment other than symptomatic antinausea and antidiarrheal drugs is available for acute radiation sickness, but some evidence suggests that early intervention with potassium iodide can reduce the incidence of some long-term thyroid effects, especially in children (Verger et al., 2001; Zanzonico and Becker, 2000).
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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program The rate of decay of the commonly used radioactive materials is very slow, so contamination is a serious clinical concern. Although not invisible, a finely ground or powdered agent could be detected and removed only with the aid of special detection equipment. Ionizing radiation comes in four forms, and although there are detectors for each of the four forms, no one piece of equipment on the market meets all detection requirements. The activities required to cope with an incident involving a radiological weapon may resemble those outlined in either Figure 1-1 or Figure 1-2, depending on whether the attack is overt (perhaps a conventional bomb wrapped in highly radioactive material) or covert (introduction of radioactive dust into an air, water, or food supply). THE MMRS PROGRAM Today’s MMRS program has evolved from an idea originally developed in the metropolitan Washington, D.C., area in 1995. Using the combined personnel and equipment resources from Washington, D.C., Arlington County in Virginia, and Montgomery and Prince Georges Counties in Maryland, the Metropolitan Medical Strike Team (MMST) received training, equipment, and supplies specifically designed to facilitate an effective response to a mass-casualty terrorism incident with a WMD. The first of its kind in the civilian environment, the MMST was designed to provide initial, on-site emergency health, medical, and mental health services after a terrorist incident involving CBR materials. The team’s mission includes CBR agent detection and identification, patient decontamination, triage and medical treatment, emergency transportation of patients to local hospitals, coordination of movement of patients to more distant hospitals via the National Disaster Medical System, and planning for the disposition of nonsurvivors. Building from the initial efforts of the Washington Metropolitan Area MMST, the DHHS Office of Emergency Preparedness (OEP) funded the development of a similar team in Atlanta, Georgia, in preparation for the 1996 Summer Olympic Games. The program expanded further when the U.S. Congress, as a part of the Defense Against Weapons of Mass Destruction Act of 1996, directed the Secretary of Defense to take immediate actions to both enhance the capability of the federal government to respond to terrorist incidents and to support improvements in the capabilities of state and local emergency response agencies. In recognition of this requirement, an amendment (widely known as the Nunn-Lugar II or Nunn-Lugar-Domenici Amendment, after its sponsors in the U.S. Senate) to the National Defense Authorization Act for Fiscal Year 1997 (P.L. 104-201) authorized $100 million to establish a military rapid response unit; to implement programs providing advice, training, and loan of equipment to state and local emergency
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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program TABLE 1-2 Biological Agents, Effects, Characteristics, and Medical Countermeasures Disease (Agent) Effects of Inhalation Incubation Period Anthrax (Bacillus anthracis) Fever, headache, fatigue, cough, dyspnea, death if untreated (the cutaneous form with black eschar has a much lower mortality rate) 1–5 days (up to 60 days possible) Botulisma (Clostridium botulinum toxin) Blurred vision, photophobia, difficulty speaking, progressive paralysis, respiratory failure, death 1–5 days Brucellosisb (six species of the Brucella bacterium) Fever, headache, chills, weakness, sweating, weight loss; seldom fatal 5–60 days Hemorrhagic fevera (a dozen viruses from the families Arenaviridae, Bunyaviridae, Filoviridae, and Flaviviridae) High fever, low blood pressure, subcutaneous hemorrhage, bleeding from mucous membranes, organ failure, death 4–21 days Plague (Yersinia pestis) Fever, chills, headache, nausea, vomiting, pneumonia and bloody sputum, septicemia, death 2–3 days Smallpox (variola virus) Fever, malaise, headache, backache, abdominal pain, rash, death in 20–30 percent of those exposed 7–17 days Tularemia (Francisella tularensis) Fever, weakness, prolonged weight loss; seldom fatal 2–10 days aAdded to MMRS program contracts beginning in 1999. bDeleted from MMRS program contracts beginning in 1999. response agencies; and to provide assistance to major cities in establishing “medical strike teams” (emphasis added). This legislation provided funds in fiscal year 1997 for OEP to contract with the cities of Anchorage, Baltimore, Boston, Chicago, Columbus (OH), Dallas, Denver, Detroit, Honolulu, Houston, Indianapolis, Jacksonville, Kansas City (MO), Los Angeles, Memphis, Miami, Milwaukee, New York, Philadelphia, Phoenix, San Antonio, San Diego, San Francisco, San Jose, and Seattle. Similar appropriations in subsequent years allowed further
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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program Communicability Prophylaxis Treatment None; however, spores can survive for years outside the host Preexposure: vaccine in use since 1960s Postexposure: oral antibiotics for 30 days plus vaccine or oral antibiotics for 60 days without vaccine Inhalation: Intravenous antibiotics two times/day for 7 days and then orally for 53 days Cutaneous: oral antibiotics for 60 days None Vaccine available only through CDC Supportive therapy; antitoxin available only through CDC None No vaccine approved Oral antibiotics daily for 6 weeks From patient fluids Approved vaccine only for yellow fever Supportive therapy, ribavirin for some viruses Highly contagious via aerosol route Preexposure: vaccine no longer available Postexposure: oral antibiotics for 7 days Intravenous antibiotics twice daily for 14 days Highly contagious via aerosol or contact with pustules Vaccine is available only through CDC Symptomatic treatment only None Postexposure: oral antibiotics for 14 days Intravenous antibiotic for 7–21 days SOURCES: Franz et al. (1997)), Institute of Medicine (1999), and Centers for Disease Control and Prevention (2001a,b). expansion, and by Spring 2002, OEP had written contracts with 122 cities and was preparing to contract with 25 more. Perhaps because the immediate stimulus for the program had been an incident in 1995 involving the release of a military nerve agent (sarin) in the Tokyo subway, the first two MMSTs were essentially enhanced hazardous materials (hazmat) teams; and their plans, training, and equipment centered around dealing with chemical agents. Some of the other early MMRS program cities changed the MMST concept by integrating strike team capabilities into existing fire department, emergency medical
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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program services, and police training and organizational infrastructures. In addition, their plans incorporated local public health officials; nongovernmental organizations; state agencies, including the National Guard; federal military and nonmilitary officials; and private health care organizations. OEP soon amended the initial contracts to focus more attention on coping with a covert release of a biological agent and changed the name of the program to the Metropolitan Medical Response System. The new name emphasizes that the program is intended to enhance the capabilities of existing systems that involve not just hazmat personnel, law enforcement personnel, emergency medical services personnel, public hospitals, and the American Red Cross but also public health agencies and laboratories, private hospitals, clinics, independent physicians, and other private-sector organizations. This emphasis on enhancing existing systems rather than creating new and perhaps competing, CBR weapon-specific systems was strongly recommended by a previous IOM committee as a first principle in efforts to prepare for CBR terrorism (Institute of Medicine, 1999). The contracts between OEP and the MMRS program cities provide funds for special equipment and a cache of pharmaceuticals and medical supplies, and in turn demand detailed plans on how the city will organize and respond to chemical and biological terrorism incidents. A large number of these cities have now produced acceptable plans, and OEP turned to IOM for assistance in evaluating the extent to which its efforts and these plans have actually prepared cities to cope with the consequences of mass-casualty terrorism with a CBR agent (i.e., are the cities now well-prepared, and how has OEP contributed?). Specifically, OEP approached IOM about its ongoing need to a) systematically assess and evaluate the status of each MMRS program city (determining whether the program was having its intended effect of increasing preparedness) and b) understand the effectiveness of the overall program approach (determining whether OEP is doing an effective job of managing the program). Continuing improvement, as in any program, is critically dependent on regular evaluations of successes and shortcomings, a task rendered more difficult in this case by the low rate of actual incidents of terrorism involving CBR weapons. CHARGE TO THE COMMITTEE OEP charged the IOM Committee on Evaluation of the Metropolitan Medical Response System Program as follows: IOM shall identify and develop performance measures and systems to assess the effectiveness of, and to identify barriers related to, the MMRS development process. Additionally, IOM shall establish appro-
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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program priate evaluation methods, tools, and processes, based upon the performance measures, to assess the MMRS development process. In Phase I, an expert committee shall identify, recommend, and develop performance measures and systems to assess the effectiveness of, and identify barriers related to, the MMRS development process at the site, jurisdictional, and governmental levels. When developing the performance measures the contractor should include the following: How can OEP measure, at the program level, whether the strategies, resources, mechanisms, technical assistance, and monitoring processes provided to the MMRS development process are effective? How can OEP identify whether the performance objectives identified in the MMRS contract lead communities to preparedness? What modifications, additions, and/or subtractions should be made to these performance objectives to assist communities throughout the development process? How can existing standards be used to validate these performance objectives? If standards do not exist, how can new standards be created and/or the performance objectives be validated? What strategies have communities used to enhance their existing capabilities? What are the most effective means to measure these additional capabilities? Can relationships between traditional first responders/public safety officials and their supporting hospitals/public health offices be assessed? If so, how? What tools and/or models exist to measure preparedness for natural disasters? Do current federal performance measures for natural disasters or other programs (mitigation and response) have application to WMD terrorism preparedness (e.g., Project IMPACT)? How can casualty assumptions, for communities of varying populations, be established (percentage of population, historical data)? How can OEP measure the preexisting systems, methodologies, and plans that are used by public safety, public health, and health services agencies to communicate during day-to-day operations? How can OEP measure the impact that the MMRS development process has had on the level and/or expectations for this communication? How can financial barriers related to WMD preparedness be identified and measured? In Phase II, the committee shall use the performance measures developed from Phase I to recommend and then develop appropriate evaluation methods, tools, and processes to assess the MMRS development process. When developing these methods, tools, and processes the committee should, at a minimum, address the following:
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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program What is the most appropriate approach/model to evaluate the MMRS development process (e.g., surveys, interviews, review of plans, peer review, operational tests, etc.)? Is there an appropriate sample size that would adequately represent the impact of the MMRS development process? Considering the variance in local health systems, how can OEP appropriately draw meaningful conclusions from the results of this evaluation? The evaluation system(s) developed should be geared toward the timely assessment of each deliverable or phase of the development process with emphasis placed on identifying barriers, identifying solutions, and sharing successes of both the technical and administrative components of the MMRS program. A Phase I report delivered to the sponsor in October 2001 (Institute of Medicine, 2001) provided some initial observations on the program and its management, answered the specific questions posed by OEP for consideration during Phase I of the project. Because the primary measure of effectiveness for any program is the extent to which it achieves its ultimate goals, the Committee also identified almost 500 preparedness indicators that might be used to assess the response capabilities of MMRS program cities at the site, jurisdictional, and governmental levels. Those indicators are described in the committee’s Phase I report (Institute of Medicine, 2001) and are reprinted here in Appendix E. In Phase II, the committee used the preparedness indicators established in Phase I to develop usable evaluation methods, tools, and processes for assessing both program management by OEP and the capabilities of the local communities necessary for effective response to CBR terrorism. Those methods, tools, and processes are the subject of this second and final report. METHODS OF THE PRESENT IOM STUDY In the autumn of 2000, IOM assembled a committee whose members provided expertise in the fields of emergency medicine, emergency and disaster management, urban planning, epidemiology, public safety, public health, hospital administration, infectious diseases, mental health services, and program evaluation. This was accomplished in accordance with the established procedures of the National Academies, including an examination of possible biases and conflicts of interest and the provision of an opportunity for public comment. Brief biographies of each of the committee members are provided in Appendix A. The committee used a wide variety of sources to assemble the data and information necessary to respond to its charge. An initial organiza-
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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program tional and data-gathering meeting of the committee in December 2000 provided an overview of the MMRS program from the viewpoints of both OEP and several of the initial MMRS program cities. Other speakers provided an overview of program evaluation principles and practices and some insights into two Federal Emergency Management Agency (FEMA) programs focused on assessing state and local readiness for a variety of potential disasters. At a subsequent meeting, in February 2001, the committee learned details of the legislative and executive origins of the MMRS program and other federal counterterrorism programs. At that same meeting representatives from the U.S. Department of Justice and the Centers for Disease Control and Prevention described their current programs aimed at enhancing state and local capabilities, and a Public Health Service project officer described the different approaches and levels of success achieved by the 16 MMRS program cities in his geographic area. In addition, that meeting also featured briefings on the assessment techniques and procedures used by medical organizations evaluating residency programs, poison control centers, and individual physician specialists and by FEMA’s National Urban Search and Rescue Team program. Discussions with the speakers provided more detailed information and points of contact for additional questions. As additional sources of information, the sponsor’s project officers shared file copies of completed plans from six MMRS program cities and offered committee members contacts and resources in the OEP offices that had relevant data. The committee members themselves contributed both personal contacts and specific information from their own files and experience. The World Wide Web provided much information about additional organizations and training in counterterrorism; and the committee staff assembled a library of more than 500 documents, published and unpublished, bearing on federal, state, and local preparations for managing the consequences of a terrorist incident involving a CBR weapon.1 An interim Phase I report, released in October 2001, was the result of extensive discussion among the committee members at a 2-day meeting in May 2001 during which the committee drafted answers to each of the specific questions asked by OEP in its charge to the committee and compiled initial preparedness indicators. Subsequent revisions of the preparedness indicators were reviewed and modified via email, and committee members signed off on the review draft in late July 2001. After review 1 These documents and other written materials presented to the committee are maintained by the Public Access Office of the National Research Council Library. Appointments to view these materials may be made by telephoning the library at (202) 334-3543 or by sending an e-mail to firstname.lastname@example.org.
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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program by a panel of nine independent reviewers and attendant revisions to the manuscript, the Phase I report was released in October 2001 (Institute of Medicine, 2001). A similar process, with meetings held in October 2001 and January 2002, led to the present report. ORGANIZATION OF THIS REPORT Following this introductory chapter, Chapter 2 describes emergency response systems, local, state, and federal, and how the MMRS program fits into those activities.2 Chapter 3 describes federal programs other than the MMRS program that aim at proactively strengthening state and local capabilities to respond to CBR terrorism. Chapter 4 describes the details of the contracts between OEP and the MMRS program cities that define the program. Chapter 5 provides an overview of evaluation concepts and introduces some principles for application to the MMRS program. Chapter 6 describes the committee’s derivation of nearly 500 potential preparedness indicators (the indicators themselves are provided in Appendix E). Chapter 7 addresses OEP’s management of the program by providing OEP with a self-report instrument with which to query MMRS program communities about their perceptions of the MMRS program and OEP’s administration of the program. Chapter 8 addresses the effectiveness of the program itself. It draws on a subset of the preparedness indicators to describe the committee’s recommendations for a three-part program for assessing the capabilities of the MMRS program communities. Finally, Chapter 9 presents a brief summary and the committee’s overall conclusions and recommendations for improving the MMRS program. Appendixes provide brief biographies of the committee and staff, descriptions of federal teams available to respond to the scene of terrorism involving a CBR agent, a list of MMRS program cities, the checklist with which OEP evaluates MMRS contract compliance, a collection of nearly 500 preparedness indicators potentially applicable to the MMRS program that was the product of phase I of this IOM project, and fictional biological, chemical, and radiological scenarios with discussion questions. 2 The committee is indebted to Lauren Schiff for a commissioned paper that was the basis for Chapter 2.
Representative terms from entire chapter: