This paper considers “lessons learned” from the March 20, 1995 covert terrorist attack on the Tokyo, Japan subway system employing a neurotoxic agent. The following lessons from this disaster are reviewed in light of prevailing practice and policy in the U.S. in 2005: timely communication of vital information; operational logistics including triage, surge capacity and decontamination; secondary contamination of emergency responders and hospital personnel; assessment and treatment of the “worried well”; secondary traumatization of rescue workers; and behavioral health preparedness measures and treatment for disaster victims. In some respects little progress has been made, for instance, in developing new, evidence-based therapies for disaster victims with posttraumatic stress disorder. On the other hand, some recently developed and implemented initiatives such as the Strategic National Stockpile (SNS), represent enhancements to U.S. preparedness compared to that which existed during the 1995 terrorist attacks on the Tokyo, Japan subway system.
ABC News. com. (2001). The Terror of the Times: Bioterror Fever Grips the World Available at http://abcnews.go.com/International/story?id=80475&page=1 accessed 12/30/04.
2.
AHRQ. (2004). Publication No. 04-P008. Optimizing surge capacity: Hospital Assessment and Planning. Bioterrorism and Health System Preparedness, Issue Brief No. 3. Available at http://www.ahrq.gov/news/ulp/btbriefs/btbrief3.htm accessed 12/30/04.
3.
Asnis, G. M., et al. (2004). SSRI’s versus non-SSRI’s in post-traumatic stress disorder: An update with recommendations. Drugs, 64(4), 383-404.
4.
Auf der Heide, E. (1996). Disaster planning Part II: Disaster problems, issues and challenges identified in the research literature. Emergency Medicine Clinics of North America, 14(2), 453-480.
5.
Ballenger, J. C., Davidson, J. R., Lecrubier, Y., Nutt, D. J., Foa, E. B., Kessler, R. C., McFarland, A. C., & Shalev, A. Y. (2000). Consensus statement on posttraumatic stress disorder from the International Consensus group on Depression and Anxiety. Journal of Clinical Psychiatry, 5, 60-66.
6.
Bartholomew, R. E., & Wessely, S. (2002). Protean nature of mass sociogenic illness: From possessed nuns to chemical and biological terrorism fears. British Journal of Psychiatry, 180, 300-306.
7.
Beaton, R., & Johnson, C. (2002). Evaluation of domestic preparedness training for first responders. Prehospital and Disaster Medicine, 17, 119-125.
8.
Beaton, R., & Murphy, S. (2002). Psychosocial responses to biological and chemical terrorist threats and events: Implications for the workplace, Journal of the American Association of Occupational Health Nurses, 50(4), 182-189.
9.
Beaton, R., Murphy, S., Johnson, C., Pike, K., & Corneil, W. (1999). Coping responses and posttraumatic stress symptomatology in urban fire service personnel. Journal of Traumatic Stress, 12, 293-308.
10.
Beaton, R., Murphy, S., Johnson, C., & Nemuth, M., (2004). Secondary traumatic stress response in firefighters in the aftermath of 9/11/2001. Traumatology, 10, 7-16.
11.
Beaton, R., Oberle, M., Wicklund, J., Stevermer, A., & Owens, D. (2003). Evaluation of the Washington State National Pharmaceutical Stockpile Dispensing Exercise Part I - Patient Volunteer Findings. Journal of Public Health Management and Practice, 9, 368-376.
12.
Beaton, R., Oberle, M., Wicklund, J., Stevermer, A., & Owens, D. (2004). Evaluation of the Washington State National Pharmaceutical Stockpile Dispensing Exercise Part II - Dispensary Site Worker Findings. Journal of Public Health Management and Practice, 10, 77-85.
13.
Becker, S. M. (2004). Emergency communication and information issues in terrorist events involving radioactive materials. Biosecurity And Bioterrorism: Biodefense Strategy, Practice, And Science, 2(3), 195-207.
14.
Centers for Disease Control and Prevention (CDC). (2004). Continuation Guidance -Budget Year Five Attachment J-CHEMPACK Public Health Preparedness and Response for Bioterrorism available at http://www.bt.cdc.gov/planning/continuationguidance/pdf/chempack-attachj.pdf, accessed 01/04/05.
15.
Copass. (2002). Personal communication from director of Harborview Medical Center Trauma Unit.
16.
Department of Homeland Security (DHS). (2003). Top Officials (TopOff)Exercise Series: TopOff 2. After Action Summary Report for Public Release. Available at http://www.dhs.gov/interweb/assetlibrary/Initial_NRP_100903.pdf, accessed 12/30/04.
17.
Department of Justice (DoJ). (2002). Arlington County After-action Report on the September 11 Terrorist Attach on the Pentagon. Prepared by Titan Systems Corporation. Contract Number G310F0084K, order number 2001F_341.
18.
DeWolfe, D. (2003). Population Exposure Model in U.S. Department of Health and Human Services. Mental Health All-Hazards Disaster Planning Guidance, Available at http://www.mentalhealth.org/publications/allpubs/SMA03-3829/, accessed 12/30/04.
19.
Esbitt, D. (2003). The strategic national stockpile: Roles and responsibilities of health care professionals for receiving stockpile assets. Disaster Management Response, 1, 68-70.
20.
Evans, R. G., Crutcher, J. M., Shadel, B., Clements, B., Bronze, M. S. (2002). Terrorism from a public health perspective. The American Journal of the Medical Sciences, 323(6), 291-298.
21.
Federal Emergency Management Agency (FEMA). (2003). Preparedness-Emergency Operations Center and Interoperable Communications Grants. Available at http://www.fema.gov/preparedness/eoc_grants.shtm, accessed on 12/30/04.
22.
Glik, D., Harrison, K., Davoudi, M., & Riopelle, D. (2004). Public perceptions and risk communications for Botulism. Biosecurity And Bioterrorism: Biodefense Strategy, Practice, And Science, 2(3), 216-223.
23.
Hafen, B., Karren, K., & Mistrovich, J. (1992). Prehospital Emergency Care. Brady Prentice Hall: NJ, 798-801.
24.
Hall, M., Norwood, A. E., & Fullerton, C. S. (2002). Preparing for bioterrorism at the state level: Report of an informal survey. American Journal of Orthopsychiatry, 72(4), 486-491.
25.
Havlak, R., Gorman, S. E., & Adams, S. A. (2002). Challenges associated with creating a pharmaceutical stockpile to respond to a terrorist event. Clinical Microbiological Infection, 8, 529-533.
26.
Health and Human Services (HHS). (2003). Mental Health All Hazards Disaster Planning Guidance. Available at http://media.shs.net/ken/pdf/SMA03-3829/All-HazGuide.pdf, accessed 01/04/05
27.
Health Resources and Services Administration (HRSA). (2004). Focus on Bioterrorism. HRSA requirements available at www.hrsa.gov, accessed 12/30/04.
28.
Holstege, C., Kirk, M., & Sidell, F. (1997). Chemical Warfare: nerve agent poisoning. Critical Care Clinicians, 13(4), 923-942.
29.
Jagninas, L., & Erdman, D. (2004). CBRNE - Chemical Decontamination. E-medicine, Available at http://www.emedicine.com/emerg/topic893.htm, accessed on 12/3004.
30.
Joint Committee on Accreditation of Healthcare Organizations (JCAHO) available at www.jcaho.org, accessed 12/30/04.
31.
Kawana, N., Ishimatsu, S., Matsui, Y., Tamki, S., & Kanda, K. (2005). The chronic posttraumatic stress symptoms in victims of Tokyo subway sarin gas attack. Traumatology, the International Journal, 11(2).
32.
Krystal, J. H., Kosten, T. R., Southwick, S., Mason, J. W., Perry, B. D., & Giller, E. L. (1989). Neurobiological aspects of PTSD: Review of clinical and preclinical studies. Behavior Therapy, 20, 177-198.
33.
Marks, I., Lovell, K., Noshirvani, H., Livanou, M., Thrasher, S. (1998). Treatment of posttraumatic stress disorder by exposure and/or cognitive restructuring a controlled study. Archives of General Psychiatry, 55, 317-325.
34.
Mariotti, D. (2004) Emergency Preparedness Liaison Harborview Medical Center, Personal Communication.
35.
Matsui, Y., Ohbu, S., & Yamashina A. (1996 July). Hospital deployment in mass sarin poisoning incident of the Tokyo subway system - an experience at St. Luke’s International Hospital, Tokyo. Japan Hospital, 15, 67-71.
36.
McFarlane, A. C. (1989). The aetiology of post-traumatic morbidity: Predisposing, precipitating and perpetuating factors. British Journal of Psychiatry, 154, 221-228.
37.
McNally, R., Bryant, R., & Ehlers, A. (2003). Does early psychological intervention promote recovery from post traumatic stress? Psychological Science in the Public Interest, 4, 45-79.
38.
Medical Program Director - Pierce County. (2005). Pierce County Emergency Medical Services Patient Care Protocol. Department of Emergency Management, Revised January 2005.
39.
Mitchell, J. T., & Everly, G. S., Jr. (2001). Critical Incident Stress Debriefing: An operations manual for CISD, defusing and other group crisis intervention services (3rd ed.). Ellicott City, MD: Chevron.
40.
Morgan, C. A., Krystal, J. H., & Southwick, S. M. (2003). Toward early pharmacological posttraumatic stress intervention. Biological Psychiatry, 53(9), 834-843.
41.
National Institute of Mental Health (NIMH) Mass Violence: Mental Health and Mass Violence: Evidence-Based Early Psychological Intervention for Victims/Survivors of Mass Violence. Available at http://www.nimh.nih.gov/healthinformation/massviolence_intervention.cfm, accessed 12/30/04.
42.
National Institute for Occupational Safety and Health (NIOSH). (2001). Psychological First Aid Website available at http://www.cdc.gov/niosh/unp-trinstrs.html, accessed 12/30/04.
43.
National Mental Health Information Center (NMHIC). (2000). Field Manual for Mental Health and Human Service Workers in Major Disasters. Available at http://www.mentalhealth.org/publications/allpubs/ADM90-537/default.asp, accessed 12/30/04.
44.
Norris, F. H., Friedman, M. J., Watson, P. J., Byrne, C. M., Diaz, E., de Kaniasty, K. (2002). 60,000 disaster victims speak: Part I. An empirical review of the empirical literature, 1981-2001. Psychiatry, 65, 207-239.
45.
North, C. S., Nixon, S. J., Shariat, S., Mallonee, S., McMillen, J. C., Sptiznagel, E. L., & Smith, E. M. (1999). Psychiatric disorders among survivors of the Oklahoma City bombing. Journal of the American Medical Association, 282(8), 755-762.
46.
North, C., & Pfefferbaum, B. (2002). Research on the mental health effects of terrorism. Journal of the American Medical Association, 288, 633-636.
47.
Ohbu, S., Yamashina, A., Takasu, N., Yamaguchi, T., Murai, T., Nakano, K., Matsui, Y., Mikami, R., Sakurai, K., & Hinohara, S. (1997). Sarin poisoning on Tokyo subway. Southern Medical Journal, 90(6), 587-598.
48.
Occupational Safety and Health Administration (OSHA). (2004). Technical Manual. Personal Protective Equipment, Available at http://www.osha.gov/dts/osta/otm/otm_viii/otm_viii_1.html, accessed on 12/30/04.
49.
Okamura, T., Suzuki, K., Fukuda, A., Kohama, A., Takasu, N., Ishimatsu, S., & Hinohara, S. (1998a). The Tokyo subway sarin attack: Disaster management, Part 1: Community emergency responses. Academic Emergency Medicine, 5(6), 613-617.
50.
Okumura, T., Suzuki, K., Fukuda, A., Kohama, A., Takasu, N., Ishimatsu, S., & Hinohara, S. (1998b). The Tokyo subway sarin attack: Disaster management, Part 2: Hospital response. Academic Emergency Medicine, 5(6), 618-624.
51.
Okumura, T., Suzuki, K., Fukuda, A., Kohama, A., Takasu, N., Ishimatsu, S., & Hinohara, S. (1998c). The Tokyo subway sarin attack: Disaster management, Part 3: National and international responses. Academic Emergency Medicine, 5(6), 624-627.
52.
Pastel, R. H. (2004). Psychological effects of ‘weapons of mass disruption’. Psychiatric Annals, 34(9), 679-686.
53.
Pfefferbaum, B. (1999). Mental health services for children in the first two years after the 1995 Oklahoma City terrorist bombing. Psychiatric Services, 50(7), 956-958.
54.
Pfefferbaum, B., North, C. S, Flynn, B. W., et al. (2002). Disaster mental health services following the 1995 Oklahoma City bombing: Modifying approaches to address terrorism. International Journal of Neuropsychiatric Medicine, 7(8), 575-579.
55.
Pitman, R. K., Sanders, K. M., Zusman, R. M., et al. (2002). Pilot study of secondary prevention of posttraumatic stress disorder with Propranolol. Biological Psychiatry, 51, 189-142.
56.
Raskind, Murray A., et al. (2003). Reduction of nightmares and other PTSD symptoms in combat veterans by Prazosin: A placebo-controlled study. American Journal of Psychiatry, 160, 371-373.
57.
Resick, P. A., Nishith, P., Weaver, T. L., Astin, M. C., & Feuer, C. A. (2002). A comparison of cognitive-processing therapy with prolonged exposure and a waiting condition for the treatment of chronic posttraumatic stress disorder in female rape victims. Journal of Consulting and Clinical Psychology, 70, 867-879.
58.
Ritchie, E. C., Friedman, M., Watson, P., Ursano, R., Wessely, S., & Flynn, B. (2004). Mass violence and early mental health intervention: A proposed application of best practice guidelines to chemical, biological, and radiological attacks. Military Medicine, 169(8), 575-578.
59.
Schlenger, W. E., Caddell, J. M., Ebert, L., Jordan, B. K., Rourke, K. M., Wilson, D., Thalji, L., Dennis, J. M., Fairbank, J. A., & Kulka, R. A. (2002). Psychological reactions to terrorist attacks: Findings from the National Study of Americans’ reactions to September 11. Journal of the American Medical Association, 288, 581-588.
60.
Schuster, M. A., Stein, B. D., Jaycox, L. H., Collins, R. L., Marshall, G. N., Elliott, M. N., Zhou, A. J., Kanouse, D. E., Morrison, J. L., & Berry, S. H. (2001). A national survey of stress reactions after the September 11, 2001 terrorist attcks. New England Journal of Medicine, 345(20), 1507-1512.
61.
Shariat, S., Mallonee, S., Kruger, E., Farmer, K., & North, C. (1999). A prospective study of long-term health outcomes among Oklahoma City bombing survivors. Journal of Oklahoma State Medical Association, 92(1), 178-186.
62.
Stanovic, J. K., James, K. A., & Vandevere, C. A. (2001). The effectiveness of risperdone on acute stress symptoms in adult burn patients: A preliminary retrospective pilot study. Journal of Burn Care Rehabilitation, 22(3), 210-213.
63.
Stein, B. D., Taneilian, T. L., Eisenman, D. P., Keyser, D. J., Burnam, M. A., & Pincus, H. A. (2004). Emotional and behavioral consequences of bioterrorism: Planning a public health response. The Milbank Quarterly, 82, 1-32.
64.
Taneda. (2005). The sarin nerve gas attack on the Tokyo subway system: Hospital response to mass casualties. Traumatology, the International Journal, 11(2).
65.
Tarrier, N., Pilgrim, H., Sommerfield, C., Faragher, B., Reynolds, M., Graham, E., & Barrowclough, C. (1999). A randomized trial of cognitive therapy and imagined exposure in the treatment of chronic posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 67, 13-18.
66.
The White House. (2004). Watch Program available at http://www.whitehoU.S.e.gov/bioshield/bioshield2.html, accessed 12/30/04.
67.
Vanderford, M. L. (2004). Breaking new ground in WMD risk communication: The pre-event message development projectBiosecurity And Bioterrorism: Biodefense Strategy, Practice, And Science2,(3), 193-194.
68.
Van der Kolk, B. A. (1988). The trauma spectrum: The interaction of biological and social events in the genesis of the trauma response. Journal of Traumatic Stress, 1, 273-290.
69.
Van der Kolk, B. A. (1994) The body keeps the score: Memory and the evolving psychobiology of PTSD. Harvard Review of Psychiatry, 1, 253-265.
70.
Wray, R., & Jupka, K. (2004). What does the public want to know in the event of a terrorist attack using Plague? Biosecurity And Bioterrorism: Biodefense Strategy, Practice, And Science, 2(3), 208-215.
71.
Yehuda, R., Giller, E. L., Southwick, S. M., Lowy, M. T., & Mason, J. W. (1991). Hypothalamic-pituitary-adrenal dysfunction in posttraumatic stress disorder. Biological Psychiatry, 30, 1031-1048.
