1. Terrorism can be defined as criminal acts or threats by individuals or groups to achieve political, social or economic gain or recognition by fear, intimidation, coercion, or violence against the government and its citizens.
    
2. Domestic acts of terrorism have been committed in the past and are likely to occur in the future.
    
3. International acts of terrorism have been committed in the past and are likely to occur in the future.
    

1. A large‑scale emergency may result in increased demands on all personnel.
    
2. Many injuries, both minor and relatively severe, will be self‑treated by the public. 
    
3. Resources available through area and regional medical, health and mortuary services mutual aid agreements will be provided.
    
4. When local resources can no longer meet the demand of the situation, State agencies will be contacted to provide additional resources and/or to assume control of the response.
    
5. Catastrophic terrorist events may affect large areas of the County and response and auxiliary resources may be damaged, destroyed, or unavailable.
    
6. Terrorist are likely to deploy weapons of mass destruction including explosives, chemical and biological weapons.
    
7. That it will be unlikely that initial emergency response personnel will know the event is linked to terrorist activity.
    
8. That intelligence agencies will share information and fully cooperate with response personnel.
    

9. Terrorist activity will likely include a variety of public and private sector �targets�, such as public buildings, nuclear plants, schools, etc.
    

1. Emergency operations will be an extension of normal agency and facility duties.
    
2. Coordination between all agencies is necessary to ensure emergency operational readiness.

1. Be responsible for overall coordination of the Emergency Operations Center and the activities that occur within the EOC.
    
2. Is responsible for overall plan development and the training of personnel in the plan to ensure each is familiar with the plan and their roles and responsibilities.
    
3. Be responsible for overall coordination with state and federal agencies likely to respond to incidents of terrorism and shall provide lead coordination with all local agencies as appropriate.
    
4. Provide communications with an coordination with local, state and national elected officials and hold briefings of such officials as necessary.

Health:

In addition to those responsibilities outlined in the County Emergency Operations Plan, the Health Director shall:
 

1. Address the primary concern of public health disease control and biological detection and control. The County Department of Health will implement effective environmental health, nursing and health education practices to minimize the incidence of disease as well as biological detection and control. This service is unique to the County and includes services to the municipalities.
    

2. Conduct frequent inspections of damaged housing and emergency shelters necessary to determine the need for emergency repairs, pest control, sanitation, or other protective procedures, such as biological decontamination.
    

3. Inspect private water supplies as necessary by the Health Department due to their proximity to flood areas or a hazardous materials incident. The Health Department will respond to requests by residents as needed in addition to identification of areas that may need mandatory inspection.
    

4. Make recommendations for immunizations or other preventive measures.
    

5. Be responsible for the development of emergency plans dealing with bio-terrorism, biological contaminants, or incidents where biological agents are used or are likely to be used and ensuring that such personnel are trained in their roles and responsibilities accordingly.
    
6. Coordinate with the North Carolina Medical Examiners Office when essential in the event of mass fatalities and the need for identification and determination of cause of death. This coordination will be a co-responsibility of the Health Director and the County Medical Examiner.

1. Be responsible for investigations to determine the extent of an incident and those responsible.
    

2. Collect evidence, conduct crime scene control security and if necessary or warranted, evacuation of the affected area.
    

3. Coordinate with state and federal law enforcement agencies.
    
4. Gather and appropriately disseminate intelligence information.
    
5. Be responsible for the development of specialized response plans to terrorism incidents involving law enforcement personnel and for ensuring that such personnel are trained in their roles and responsibilities accordingly.

1. Coordinate emergency fire service response in cooperation with the command authority of individual responding departments.
    
2. Ensure the Incident Command System (ICS) will be used.
    
3. Coordinate expansion of fire service capability utilizing resources from the entire County as well as the municipalities and mutual aid departments.
    
4. Be responsible for the development of specialized response plans to terrorism incidents involving fire service personnel and for ensuring that such personnel are trained in their roles and responsibilities accordingly.

1. Take charge of the response of emergency medical service resources and coordinate the response of the various rescue resources in cooperation with the command authority of the various rescue squads in the County.
    
2. Ensure the Incident Command System (ICS) will be used.
    
3. Coordinate expansion of the emergency medical service capability utilizing resources from the entire County as well as the rescue squads and mutual aid departments.
    
4. Be responsible for the development of specialized response plans to terrorism incidents involving EMS and Rescue personnel and for ensuring that such personnel are trained in their roles and responsibilities accordingly. These plans may include field decontamination of patients, personnel and equipment.
    
5. Be responsible for coordination with local hospitals regarding response to incidents relating to patient transportation.

1. Take charge of the proper recovery of human remains and ensure that remains are appropriately decontaminated.
    
2. Coordinate with the North Carolina Medical Examiners Office when essential in the event of mass fatalities and the need for identification and determination of cause of death. This coordination will be a co-responsibility of the Health Director and the County Medical Examiner.
    
3. Conduct expansion of morgue capability utilizing resources from the state and the County.

1. Be responsible for the development of specialized response plans to terrorism incidents involving communications personnel and for ensuring that such personnel are trained in their roles and responsibilities accordingly. These plans may include state and federal communications as well as backup communications for primary dispatch channels.
    
2. Coordination with municipal communications resources as well as private resources that may be used in crisis situations.
    
3. Maintain communications with state and federal agencies as required and relay information about terrorist activity or other incident related information to the appropriate local, state and or federal agency.

1. Be responsible for the overall cooperation of all County agencies in any pre-terrorist event, during an event and in recovery operations.
    
2. Coordination with municipal governments as well as private resources that may be used in crisis situations.
    
3. Serving as chief liaison with elected officials.
    
4. Ensuring timely and accurate information is presented to elected officials and the public.

1. Be responsible for the development of information to be disseminated to the public regarding terrorism and the County plan to deal with terrorist activity.
    
2. Coordination with municipal governments as well as, hospitals and all involved agencies, including private and volunteer organizations, to ensure accurate information is given to the public and the media.
    
3. Ensure that no information is released until it has been authorized for release by the County Manager or the Emergency Management Coordinator.

1. Be responsible for the development of specialized response plans to terrorism incidents involving their respective agency or organization, and for ensuring that such agency personnel are trained in their roles and responsibilities accordingly.
    
2. Coordination with respective local, state and federal agencies of a similar function and coordination with Emergency Management.
    
3. Be prepared to brief other officials on the activity of their respective agency in a pre-terrorist event, during such an event and post event.

1. Chairman - Bertie County Board of Commissioners
2. County Manager
3. Emergency Management Coordinator
    

1. Mayor
2. Town Council or Board
3. Town Manager
    

Attachment 1
BERTIE COUNTY EMERGENCY MEDICAL SERVICE MASS CASUALTY PLAN
 

1. Definition: An M.C.I. is any event that results in multiple patients or victims. It can range in size and complexity from seven (7) or more patients spread over a small or large area at a single location or at multiple locations.
    
2. Types: The type of M.C.I. depends on the ratio of victims to EMS resources available for providing triage, treatment, and transportation.
    
   • Level One: Any incident that can be handled with minimal Bertie County EMS resources (i.e., no more than six ambulances).
   • Level Two: Any incident that can be handled with available Bertie County EMS resources up to and including rescue squad and private ambulance services (i.e., no more than twelve ambulances).
   • Level Three: Any incident that cannot be handled with in-county EMS & rescue resources (greater than twelve ambulances).

Requesting Activation of the Out-of-County Mutual Aid Plan:

• EMS Director
• On-Duty EMS Operations Supervisor
• EMS Training Officer
• On-Duty EMS Shift Coordinator

KEY PLAN COMPONENTS

1. Dispatching of units will be made on the primary EMS/Rescue frequency. All out-of-county units will make initial contact on the primary frequency also.
    
2. Communications between ambulances and the hospitals shall be on standard, designated medical communications channels, unless otherwise directed by EMS Command. The Transportation officer will give numbers of victims and the condition of each as the unit is departing from the scene.
    
3. On-scene EMS operations shall be conducted small handheld portable radios, as designated by the EMS Command.
    
4. Communications with Air MedEvac services will be conducted on standard, designated medical communications frequnecies.
    
5.  It is important that all incoming equipment have the ability to receive instructions from EMS Command and when directed, to proceed to the staging area or to the incident scene.
    
6. All radio communications shall be consistent with Bertie County EMS standard operating guidelines for radio operations.

1. Communications will estimate the initial number of transport ambulances needed.
    
2. Communications will activate EMS Group paging tones
   .
3.  Send one (1) ambulance for every two (2) patients. For example, if it is reported that ten patients are involved, five ambulances will need to be dispatched - this could be a combination of private, volunteer, local EMS, and out-of-county EMS units if necessary.
    
4. First arriving unit establishes EMS Command, provides an initial �size up,� and begins patient triage.
    
5. Critical Actions:
   • Establish command at a key location that allows good visual assessment of the entire scene if possible. Avoid high noise areas and distractions if possible.
   • Quickly determine if additional resources are required, or if number of enroute units can be reduced, and report this information to Communications.
   • Determine an area for unit staging and the best approach to the scene.
   • Upon arrival, next in unit(s) report to EMS Command for assignment and will stage vehicle in an appropriate location.
      
6. Critical Actions:
   • Once enroute, contact Communications by radio for further instructions and assignment. Keep radio transmissions brief.
   • Arriving units must stage appropriately to allow departing units to leave the scene without difficulty. Do not block vehicle entry to, or exit from, the scene.
   • For large scale incidents proceed directly to the personnel and equipment staging area, be prepared to drop additional personnel and equipment.
   • Vehicle drivers must stay with their ambulance at all times.
   • Turn off all emergency lights upon arrival.
   • Ensure that wheeled ambulance stretchers remain in the ambulance until ready for use.
   • ALL EMS PERSONNEL MUST WEAR AN EMS SAFETY VEST AT A MINIMUM � SECTION LEADERS WILL WEAR AN APPROPRIATE SECTION COMMAND VEST.

Transferring EMS Command:
 

1. Transfer of EMS Command will occur when the next higher ranking, or next most senior, EMS personnel arrive on scene.
    
2. A face-to-face exchange of information will occur and the individual assuming EMS Command will notify Communications of the transaction after command has been transferred (example, �Communications, (unit number) assuming EMS Command�).

Staging:
 

1. Initial Staging: A location for initial staging will be established for all MCI�s.
    
2.  Secondary Staging: A secondary staging location will be established for all Level 2 & Level 3 MCI�s.

1. Critical Actions:

• Be careful not to cause gridlock in the initial staging area. Only the vehicles necessary to set-up EMS Command and Triage should be located in the initial staging area.
• Consider using large parking lots located near interstates or divided highways as secondary staging locations.
• Churches, schools, shopping centers, etc. make ideal locations for secondary staging and are generally easy to find.
• All staging sites should have one way in and one way out for all traffic.
• When moving vehicles, avoid backing whenever possible. If backing a vehicle is unavoidable, the driver must have an appropriately positioned spotter at all times.

Triage & Transportation:
 

1. All patients will be triaged using the "START" method and will be tagged with a color-coded triage tag prior to arrival at an on-scene treatment area.
    
2. The EMS Transportation Officer will provide transport instructions to EMS personnel and direct patients to ambulances for transportation.
3. DO NOT communicate directly with the receiving hospital unless a patient�s condition deteriorates dramatically while enroute. The EMS Transportation Officer will communicate directly with the receiving hospitals.
    
4. You will receive instructions from Communications regarding re-assignment when leaving the receiving hospital.
    
5. Follow the directions of law enforcement and/or fire personnel regarding traffic flow.

Management of On-Scene Conflicts:
 

It is understood that each provider will make every effort to manage any multi-casualty incident in an efficient, effective, and professional manner.  However, sometimes various factors may be present which hamper these efforts.  Such factors may range from unforeseen circumstances of the incident to poor decision-making on the part of early on-scene personnel.  These situations will occur � it is a documented fact, evident in studies of every mass-casualty situation in history � and no county is immune from them!  There is a right and a wrong way to manage them, however.
 

Should any responding agency encounter situations that they believe are hampering their efforts, and other responders� efforts, to provide the most effective care, the following steps should occur:
 

1. The response agency personnel having questions/concerns about scene operations should:
   • Not argue with on-scene personnel.
   • Contact your regular duty supervisor and report the situation.
   • The Supervisor will contact his/her peers in the host agency�s response jurisdiction and work out the problem.
      
2. The host agency�s response and/or incident management personnel should:
   • Acknowledge that mutual aid responders may operate somewhat differently than you do on a day-to-day basis.
   • Accept input from mutual aid providers� supervisory personnel.
   • Do nothing that compromises patient care. 

If problems cannot be managed on scene, responders are each bound by their local protocols and best judgment, and conflicts will be managed post-incident through medical review.
 

In order to minimize the possibility of responder conflicts, agencies are encouraged to respond a supervisor or ranking officer along with treatment and transport personnel for any incidents expected to be of extended duration (i.e., 1 hour or greater in duration).
 

EMS Command Officer

• Accountable for the EMS response to an incident including not only operations but also logistics, finance, planning, safety, public information, and other aspects of the local EMS system.
• Assigns lead personnel to other sections such as staging, triage, treatment, and transportation.
• Typically a �White Shirt� or the most senior paramedic present.
• Performs accountability assessment of EMS personnel assigned to his/her section post-incident.

EMS Operations Officer

• In charge of all operational sections of the EMS response including staging, triage, treatment, and transportation.
• Ensures that sections operate smoothly and that problems are addressed early.
• Performs accountability assessment of EMS section leaders assigned to him/her post-incident.

Staging Officer

• The Staging Officer (SO) is in charge of vehicle movement in and out of a staging area.  The SO may come from any discipline (either EMS, fire, or law enforcement) but should know the area including transportation routes and road conditions.
• The SO will be in contact with on-scene command to evaluate what type of units and how many to send in at what times.
• Units responding into another county will report to the staging area, report IN PERSON to the SO, and move at their command.  Out-of-county responding units do not leave the staging area to return home without clearance from the SO.
• Performs accountability assessment of EMS personnel assigned to his/her section post-incident.

Triage Officer

• This individual is responsible for patient sorting to ensure that the most critical patients receive treatment and transport first.
• The individual selected as Triage Officer in any incident should have excellent patient assessment skills, and must be very skilled at use of triage and tagging systems.  He/she again will likely represent the host county's primary EMS provider (or possibly an emergency physician) except in unusual circumstances.
• Out-of-county responders assigned to Triage will work under the command of this individual.
• Performs accountability assessment of EMS personnel assigned to his/her section post-incident.

Treatment Officer/Medical Officer

• This individual is responsible for managing patient care either at the site of injury (if the patient cannot be extricated), at the triage area, and in the treatment area.
• Assigns leadership positions for all treatment sectors.
• The Treatment Officer will likely be a senior paramedic or member of the command staff of the host county's primary EMS provider (or possibly an emergency physician).
• Out-of-county responders assigned to Treatment will work under the command of this individual.
• Performs accountability assessment of EMS personnel assigned to his/her section post-incident.

This information has been reproduced as a laminated card and will be kept in the visor of each vehicle in the EMS fleet. Refer to this section as a quick reference or as a quick study guide.
 

May fill any leadership position in the ICS flow chart up to and including Command, Operations, Staging, Triage, Treatment, and Transportation sections. May activate regional mutual aid plan in the event of a Level 2 or Level 3 MCI. If off-duty at the time of callback, may serve as a direct liaison to the Emergency Operations Center.
 

Personnel Accountability
 

EMS Personnel will be accounted for during the post-incident stage � this will be the responsibility of each section leader. EMS personnel should not self-respond into areas where rescue operations are taking place without first requesting clearance from EMS Operations. It is very important that EMS personnel report any change in location at the scene of a major incident to his/her respective section leader prior to actually changing location.
 

EMS Rehabilitation
 

1. EMS personnel should avoid prolonged exposure to the following situations and should tentatively be rotated out on the following schedule:
   • Vehicle extrication: No more than thirty minutes at a time in ideal situations.
   • Any MCI Section (such as Triage, Treatment, Transportation, etc.); no more than 3 hours at a time in ideal situations.
   • Rehabilitation of other Emergency Services Personnel: No more than 3 hours at a time in ideal situations.
      
2. All EMS personnel should remain mindful of the importance of staying hydrated and maintaining adequate food intake during prolonged incidents.
    
3. Ranking EMS officers and section leaders must monitor personnel assigned to their area for fatigue, possible dehydration, heat related-illnesses, and other conditions that may affect their performance.

EMS Safety
 

1. The on-scene safety officer has the authority to stop unsafe activities in order to prevent injuries or harm.
    
2. All EMS must be clearly identifiable and easily seen.
    
3. Personnel must stage away from the scene of any violent event until proper safety measures have been put into place.
    
4. All EMS personnel must use appropriate PPE and safety equipment during an MCI.

CISD/EAP
 

S.T.A.R.T.

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Attachment 2
BERTIE COUNTY HEALTH DEPARTMENT - BIOTERRORISM RESPONSE PLAN
Reviewed / Updated: March 2007
 

• to increase the County�s ability to detect a covert biological attack;
• to increase and improve the County�s response to an overt or covert bioterrorist attack;
• to reduce response time by critical municipal, county, state, and federal agencies;
• to reduce the severity of injuries or disease caused by a bioterrorist attack;
• to reduce loss of life due to a bioterrorist attack; and
• to reduce the economic impact to the County.

1. Local/County Department of Public Health�s Mission and Overall Response:
   
   The Bertie County Health Department's mission is to protect the health of Bertie County�s population in a bioterrorist event to the greatest extent possible.  This translates to the development and provision of appropriate basic surveillance, detection and epidemiological investigation capacity and being able to coordinate the necessary local public health response to a real or potential bioterrorist attack.  When additional State or Federal resources are needed to respond to the event, the Department, in collaboration with the Emergency Management Director, will be responsible for coordinating local efforts with those of the assisting State and Federal agencies.
   
   In a bioterrorist event the Bertie County Health Department initially has the lead role for all disease related surveillance and control measures.  Enhancement of preparedness and response capacity at the local level for an outbreak of disease due to bioterrorism will serve the dual function of protecting the residents of Bertie County from naturally occurring infectious disease outbreaks (e.g. West Nile Virus encephalitis, influenza, etc.)
    
2. Multi-Agency Cooperation: 
   
   Response to a threat or act of bioterrorism will require the cooperation of multiple agencies. Depending on the scope, scale and duration of the event response may involve public (local, state, federal) and private sector agencies.  To assure coordinated efficient response it is imperative that local plans and protocols that establish the roles and responsibilities of each responding agency be developed.  Memoranda of understanding between and among agencies need to be developed or modified and signed. Existing agreements between potential response parties (including those between hospitals) across county or state borders should be reviewed to ensure availability of critical resources and coordinated response.
    
3. Response Capabilities: 
   
   During the first 24-48 hours after an event most response, by necessity, will be that provided from local resources. A standardized assessment of manpower, supplies and facilities within each county will help to determine each county's strengths and limitations in responding to a major outbreak of infectious disease and under what situations requests for additional assistance will be needed. The response capability of local government may be overwhelmed by a large-scale (multi-patient/multi-casualty) event. Similarly, the capability of the state to respond may be limited with a multi-site event within North Carolina.
   
   Federal response capabilities are finite and may be overwhelmed in a multi-state event as different sites compete for limited Federal resources. Therefore, local and State response entities must plan to be as self-supporting as possible.
    
4. Bertie County Agencies Planning:
   This plan assumes the existence of terrorism response planning by the critical local public and private sector agencies necessary to respond to a bioterrorist attack.
    
5. Criminal Investigation:
   
   Bioterrorism by definition is a criminal act. Law enforcement shall be notified immediately once an act of bioterrorism is suspected or identified. Response efforts shall be coordinated with local law enforcement and the FBI as necessary. 

1. Assistance Requests:
   
   Additional assistance from neighboring counties and states may be requested through mutual aid agreements.
   
   Additional assistance from private entities, state and federal agencies, and neighboring counties and states (when mutual aid agreements exist) may be requested:
   • when local resources (government response agencies and/or medical care facilities or manpower) necessary to respond to a bioterrorist threat or attack are exhausted; or
   • when local resources are inadequate, relative to the scope, scale or duration of an event; or
   • when local resources necessary to deal with a specific event do not exist within local government or the medical care communities. 
      
2. Activation:

   The Bioterrorism Response Plan is activated for all overt or covert acts of terrorism where the use of a biological agent has been confirmed or is suspected.

   All confirmed bioterrorist events will require local, state, and federal response. 
   
   Bertie County Health Department will notify the Bertie County Public Health System, all Critical Agencies, Bertie County Emergency Management, NC Public Health, and the Centers for Disease Control and Prevention (CDC).

   Bertie County Public Health System and all Critical Agencies will be activated.

   Bertie County EOC will be activated as appropriate.

   NC Emergency Management will be notified as appropriate by Bertie County Emergency Management. 

   A Joint Information Center (JIC) will be established and Bertie County Health Department, the CDC, FBI and NC Division of Public Health generated information will be routed to the JIC. These agencies will provide the JIC with information for use in responding to inquiries about the event.

   The CDC, NC Public Health, and Bertie County Health Department will establish an epidemiological investigation unit.  The regional public health response team will provide assistance as requested.

   Bertie County Health Department will establish and maintain a Public Health Operations Center (PHOC) with the Bertie County Health Director or their designee serving as Incident Commander. 

   A Joint County/State Emergency Operations Center will be established as appropriate.

   Bertie County Health Department may request outside private or public agency assistance as necessary to respond to an outbreak of disease. Requests for public health assistance should be made to NCDPH/the State Health Director.
    
3. Additional Response:
   
   In addition to these activities the following may occur. Bertie County Commissioners may declare a local State of Emergency and request State assistance. Once the Bertie County EOC and State EOC have been activated all requests for State assistance will go from the local Emergency Management Coordinator to Area Coordinators who will relay requests to the State EOC.

1. Bertie County Response:
   
   Initial responders will be law enforcement, emergency medical services, and/or fire services in an overt or rapidly identified attack or threat of attack.  In the event of a covert attack, the initial responders will likely be the Bertie County Public Health System including, but not limited to, physicians, nurses, emergency medical services, infectious disease specialists, medical examiner/morticians, veterinarians, primary care facilities, and/or medical testing laboratories. In either situation, responders will operate under a modified Incident Command System. As the response increases and additional agencies (local, State, or Federal) are involved the organization may switch to a Unified Command System.
    
2. Local Operational Control:
   
   The Bertie County Health Director assumes control of the public health investigation and response and serves as public health advisor to the County or other official designated to lead the overall response effort. Because a bioterrorism incident is a criminal act that may involve a crime scene, law enforcement may form a joint command structure with public health. As additional agencies become involved representatives from these agencies will create a UCS (Unified Command System) where decisions will be made jointly for ongoing and future operations. If the FBI defines the event as an act of terrorism, it may take control of the response.  Initially or subsequently, the Bertie County Health Department may determine that the location of the initial or subsequent command posts should not be proximate to the area of contagion or exposure.  It is imperative that law enforcement agencies understand and accommodate the public health implications of the situation so evidence gathering and other law enforcement activities do not significantly impede or interfere with the protection of the health and safety of Bertie County residents.
    
3. Lead Response Agencies:
   
   Presidential Decision Directive #39 establishes the FBI as lead for the crisis phase (when lives are in imminent danger) and FEMA, as lead for the consequence (recovery) phase of response to terrorist events.  The Governor of North Carolina has established the Division of Emergency Management, Department of Crime Control and Public Safety, as the lead agency for all state-level disaster response.
    
4. State Response:
   
   DHHS and NCDPH response will be based in the DHHS Command Post and will, as a member of the State Emergency Response Team (SERT), be part of the Unified Command and maintain staff within the State Emergency Operations Center (EOC). NCDPH will provide epidemiological investigation advice and support to the local public health response through its Communicable Disease Control Section. DHHS will assist local responders, as necessary.  If NCEM establishes a secondary EOC proximate to the event, DHHS and NCDPH may stage personnel at that site as well.  Additional epidemiological support personnel may be provided through NCDPH.  In the event the disease agent is zoonotic (contagious to humans via animals) the State Department of (DOA) may participate in the investigation and response.    NCDPH and DHHS may request additional support from CDC.  DHSS will interact with SERT to provide logistical support for its response activities. Include organizational chart for State SERT, NCDPH, etc.
    
5. Federal Response:
   
   The CDC will provide, as requested, epidemiological and laboratory support to NCDPH.  Upon request of the Governor or designee in consultation with NCDPH, the CDC will activate and deploy the NPS.  At the request of the CDC, additional resources of the U.S. Department of Health and Human Services and other Federal agencies will be made available.  If the disease agent is zoonotic in nature, the United States Department of may become involved. Additional Federal assistance may also be made available through the FBI and FEMA/DHS.
    
6. State and/or Federal Operational Control:

   If the event is large enough in scale or duration or otherwise sufficiently serious to require support from State or Federal Agencies, the UCS Operational Command Center (OCC) will expand to include representatives from those agencies following the UCS.  In general, state and federal agencies will provide assistance to the local response effort and will assume control only when requested by local authorities or directed by a higher authority. Once the SERT is activated, the NCEM Emergency Operations Center (EOC) command center will become the initial command post for response to a terrorist event.  The Director of SERT is the SERT Leader and has authority and responsibility for consequence management as delegated by the Secretary of Public Safety under NCGS 166A.  If the FBI and/or DHS/FEMA are involved in the response, they will direct emergency response jointly with the SERT.

   Once a situation has been identified as a real or potential bioterrorism event, the FBI has authority during the crisis stage (while human life is at risk) over all aspects of the criminal investigation. DHS/FEMA assumes authority during the consequence (recovery) stage. In many situations the crisis and consequence stages overlap. During that period the FBI and FEMA will jointly share authority for the response.

1. Overt Attack:
   
   In an OVERT ATTACK, where knowledge of the use of a biological agent is known before or soon after the attack, initial identification of the agent or resulting disease or toxin may be made by:

   • First responders (law enforcement, hazardous materials teams, fire departments, emergency management) trained in and equipped to provide identification of biological weapons;

   • Local health care providers who identify a cluster of illness, a syndrome, or characteristic symptoms and signs of illness associated with the specific agent/disease of concern;

   • Local or state medical examiner as a result of post mortem examination;

   • FBI;

   • North Carolina State Laboratory of Public Health, particularly as a result of requested laboratory testing performed on environmental media or biological tissues and fluids;

   • North Carolina Division of Public Health epidemiologists;

   • CDC.

   The State Laboratory of Public Health or the CDC will confirm the biological agent and/or disease, perform antibiotic sensitivity testing and other specialized tests as necessary, and recommend preferred and alternative treatments.  The FBI�s laboratories may assist in the identification of the agent, route(s) of exposure and other factors relevant to the dissemination or transmission of the agent.
    

2. Covert Attack:
   
   Because infectious agents require an incubation period prior to causing disease in those exposed and because most health care providers and others are unfamiliar with agents of bioterrorism and the symptoms and clinical features of the diseases they cause, it is likely that a covert attack with a biological agent would not result in detection for days or even weeks after the exposure occurred.
   
   In a COVERT ATTACK initial identification may be made by:
   • Local or state medical examiner as a result of post mortem examination;
   • Private laboratory or laboratory operating as part of a medical practice during routine laboratory testing performed on environmental media, or biological tissue or fluids;
   • Astute local physician or other health care provider who suspects that symptoms and signs of illness in an individual or group of individuals are unusual and are compatible with exposure to an agent associated with bioterrorism;
   • Infectious disease specialist at a hospital or other medical facility;
   • Epidemiologists and laboratory personnel at local or state public health offices and laboratories;
   • Trained emergency medical systems personnel; or
   • Epidemiologists and laboratory personnel at the CDC.

   The CDC would make confirmation of the biological agent, disease, or toxin. FBI laboratories may also confirm the identity of the agent, disease or toxin.
    

3. Transport:
   
   In either an overt or a covert attack, collection and transport of tissue, blood, or other samples that may contain the agent of concern would be made in accordance with FBI and CDC biohazard recommendations and guidelines. These will be made available through NCPH.  

• To protect and preserve human life;
• To notify all critical local, state, and federal response entities;
• To conduct an epidemiological investigation to characterize the nature of the illness or disease outbreak (if unknown) including symptoms, clinical signs, mode of transmission, incubation period, communicability; identify the agent(s) via standard and specialized laboratory procedures, identify the location(s) of the outbreak and potential source(s) and route(s) of exposure(s) and methods of control;
• To establish and maintain surveillance for new outbreaks of disease;
• To support the medical and health care community in their efforts to provide public health, mental health and clinical services for those impacted;
• To reduce/eliminate the spread of contagion or contamination;
• To minimize fear and panic on the part of the public;
• To maintain public confidence in the county�s ability to respond.

• Regional agreements with surrounding counties to assist each another;
• Cooperation and assistance provided by the North Carolina Hospital Association (NCHA) or through mutual assistance agreements between hospitals;
• NC Emergency Management through state and county mutual assistance compacts (e.g., EMAC);
• From the Strategic National Stockpile (NPS) or Vendor Managed Inventory (VMI) through the CDC (pharmaceuticals and medical supplies).

• Quarantine of hospitals or other facilities that have admitted patients exposed to or infected with an agent or diagnosed with a disease associated with bioterrorism (e.g., smallpox), until contacts and those potentially exposed have been vaccinated;
• Quarantine of hospitals or other sites that have been directly targeted by attack with an agent associated with bioterrorism (e.g., smallpox);
• Transport to alternative care facilities those under medical treatment, but not exposed to the bioterrorist agent (e.g., moving less ill or unexposed patients to another facility or area of an existing facility to accommodate more critically ill patients in need of specialized treatment and care; or, moving patients out of the ICU to other facilities to treat cases of inhalation anthrax or botulism);
• Transport to alternative care facilities those exposed to or sick from a bioterrorist agent (e.g., all anthrax cases will be treated at hospital X or all plague cases will be treated at hospital Y);
• Agreed use or procurement of facilities for evaluation or prophylaxis and treatment (e.g., utilization of a school, coliseum, or other facility for distributing antibiotic prophylaxis for to those exposed to anthrax; use of school or other facility for vaccinating individuals against smallpox);
• Home-based isolation or quarantine of exposed/infected persons and their families (e.g., plague, smallpox);
• Quarantine of all or sections of a community (e.g., pneumonic plague, smallpox);
• Voluntary or ordered closings of places people gather (e.g., churches, schools, day care centers, theaters, convention centers, restaurants, malls, stores, laundromats, and parks, etc.);
• Closing airports to all but emergency related travel into or out of the County (e.g. pneumonic plague, smallpox);
• Closing all roads, railways and other routes of travel into or out of the impacted area or the County (e.g. pneumonic plague, smallpox);
• Declaring martial law to control spread of disease, mass panic, rioting, etc.

Attachment A
 

DEFINITIONS AND ABBREVIATIONS

For the purposes of this plan the following terms shall have the following definitions: