Simulation exercises are an important part of emergency preparedness activities for the healthcare community but evidence of their impact on the response to real major incidents is limited. This project studied the impact of health emergency preparedness exercises (HEPEs) on the response to a mass casualty terrorist incident. The mixed methods study design was adopted comprising an on-line survey and follow up individual interviews. Participants were healthcare staff who took part in responses to three major terrorist incidents in the UK in 2017. Descriptive statistics and analysis of variance were undertaken with quantitative data. Content and thematic analysis methods were used for qualitative data analysis.

The deliberate release of biological agents with terrorist or criminal intent continues to pose concerns in the current geopolitical situation. Therefore, attention is still needed to ensure preparedness against the potential use of pathogens as unconventional weapons. Botulinum neurotoxin (BoNT) is one such biological threat, characterized by an extremely low lethal dose, high morbidity and mortality when appropriately disseminated, and the capacity to cause panic and social disruption. This paper addresses the risks of a potential release of the botulinum neurotoxin and summarizes the relevant aspects of the threat.