Water Crisis Case Study



Case Study: City Water Crisis

FACILITATOR VERSION

Learning Objectives

• Describe triggers for activating the Incident Command System

• Describe public health laws related to restaurant closure

• List the basic tenets of effective risk communication

• Identify and correct common misconceptions about risk communication

Instructions

Convene your local Epi Team, and provide each Epi Team member with a copy of the case study (participant version). Choose one person to act as the facilitator. This person should use the facilitator’s version of the case study.

Guidance for facilitating the case study can be found on the next page. The case study begins on page 3.

Time Allotted: 1.5 hours

Background Materials

The following trainings, found at the North Carolina Center for Public Health Preparedness Training Web Site (), are recommended for Epi Team members without prior outbreak investigation experience. They can be viewed prior to completing the case study.

1. Risk Communication

2. Incident Command Systems for Public Health

3. Public Health Agency Emergency Response Plans Part 1

Resources

North Carolina Rules Governing the Sanitation of Food Service Establishments ()

Guidance for Facilitators

Goal

The goal of working through a case study is active learning through engaged participation by each Epi Team member.

Role of Facilitator

As a facilitator, your job is to:

• Guide the Epi Team through the case study

• Involve every team member

• Moderate discussion drawing on the suggested answers to discussion questions

• Ensure key points are covered for each question

• Keep an eye on the clock

Active Participation

All team members should be involved in the discussion. One strategy for getting everyone involved is to have team members take turns reading aloud and attempting to answer questions. Facilitators should:

1. Ensure that the room set-up encourages group participation, ie. everyone seated around a table or chairs in a circle.

2. Select one team member to read aloud the first update and the first question.

3. Encourage that team member to attempt to answer the first question (regardless of his/her background).

4. Encourage other team members to add information and discuss the question.

5. Use the suggested answers to cover key point(s) that were not addressed during the discussion.

6. Have the next person read aloud the next update or question and begin an attempted answer as above – move in sequence to include everyone.

Follow this sequence until the scenario is completed, pacing discussion in order to finish the entire scenario.

Facilitation Tips

• Read the case study ahead of time so you are prepared for the discussion.

• Always remember the learning objectives for the case study.

• If one person is dominating the conversation, call on other team members.

• If someone in the group is not participating, ask his or her opinion.

• When someone asks a question, encourage other team members to provide the answer.

• Do not spend too much time providing the suggested answers to the group. Instead, encourage the team to share their opinions about possible responses to the given scenario.

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Question 1: Would your health department activate its Incident Command System (ICS) in this situation? Why or why not?

Suggested answer: Because the county has declared a state of emergency and there are many potential public health threats, it would be prudent for your health department to activate its ICS structure in this situation. It is likely that the county will activate its ICS structure at this time as well, so it is critical that the health department communicates with county emergency management. Depending on the situation, the county may or may not use Unified Command, which includes representatives from multiple agencies. The Command post may be run out of the county’s Emergency Operations Center. In many counties, the health director will serve as the local health department’s representative in the ICS system. Regardless of his or her position in the county’s ICS, the health director may still serve as the Incident Commander within the health department’s ICS structure.

The full public health implications of the flooding are not yet known, but the ICS structure is useful for dealing with a wide range of public health threats.

Group Activity

As a team, describe the structure of the Incident Command System in your health department. Choose one person to draw the ICS structure on a flip chart or white board, including the title for each position. Then each team member should describe his or her role in the ICS structure in this scenario.

Facilitator: To encourage group participation, it may be useful to choose a team member who is less familiar with the ICS structure to draw it. Other team members can provide instruction and guidance.

Then, encourage each Epi Team member to describe his or her role in the ICS structure. The specific role of each Epi Team member will vary by county. In many counties, the health director serves as the Incident Commander. Other Epi Team members could serve in the Operations, Planning, Logistics, or Finance/Administration Sections.

In this situation, it is likely that there will be an Incident Command System operating at the county level. In this case, the health director may not be the Incident Commander, but instead may serve in another capacity.

The basic structure of the Incident Command System is shown below. The structure is scalable, can be expanded in any of the listed areas depending upon the situation.

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Question 2: What actions should your health department take in response to the report of contamination in the water system?

Suggested answer: The first action is to contact the water authority to determine the extent of the suspected contamination. Next, the health department should provide public information in collaboration with the county public information officer in the Emergency Operations Center. The health department may issue a “Boil Water Advisory” for all Springfield County citizens, restaurants and businesses, until the water is known to be safe to drink. You may issue this advisory by holding a press conference; releasing a statement to local media outlets, health care providers, hospitals, and businesses; using a countywide reverse 911 system; and posting information on the health department Web site.

Your environmental health specialist may coordinate water sampling and testing in collaboration with water authority officials. You may also request assistance from your Public Health Regional Surveillance Team (PHRST) and the Occupational and Environmental Epidemiology Branch of the North Carolina Division of Public Health.

Your health department should work with county emergency management to implement the public health portion of the county’s emergency operations plan.

Question 3: What are your public health concerns at this point?

Suggested answer: You are concerned about waterborne diseases (such as Giardia, Shigella, Cryptosporidium, and norovirus) resulting from the reservoir break; injuries due to the storm and flood; foodborne illness caused by lack of electricity for proper refrigeration; mental health issues; and other health concerns resulting from people being displaced from their homes, such as lack of access to prescription medications or other medical equipment. If shelters have been opened, there is also an increased risk of disease transmission from people living in a congregate setting.

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Question 4: What do you recommend for fast food restaurants that cannot boil water on-site?

Suggested answer: They should close the restaurant until the water system has been fixed. Although bleach added to water is sufficient to kill most microorganisms in relatively clean water, it may not kill Cryptosporidium and Giardia at the recommended range of concentrations for drinking water. Bleach also would not be effective against other contaminants, including chemicals.

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Question 5: Why is water pressure important for restaurants?

Suggested answer: Without sufficient water pressure, restaurant staff and guests cannot use the toilets or thoroughly wash their hands. Restaurant employees are required to wash their hands regularly, and failure to do so can result in legal problems for the restaurant, as well as severe disease outbreaks. The lack of water pressure could also limit the ability of restaurants to properly wash dishes. Legal requirements for sanitation at restaurants including hand washing and cleaning of utensils and equipment can be found in the North Carolina Administrative Code (NCAC) Rules for the Sanitation of Food Service Establishments (deh.enr.state.nc.us/ehs/rules.htm ). It is important to note that these rules require hand washing with soap and water, rather than an alcohol-

based hand rub.

Note: Alcohol-based hand rubs should not be used by food handlers in place of washing hands with soap and water. Although these hand rubs are effective against certain disease agents (e.g. Salmonella, Campylobacter), they are ineffective against other organisms, including bacterial spores, Cryptosporidium, and certain viruses. Also, alcohol-based hand rubs are less effective when hands are visibly soiled.[1]

Question 6: There are many other agencies and organizations besides restaurants that need sufficient water pressure to operate. What are some other agencies that the environmental health specialists and other Epi Team members would be contacting in this situation?

Suggested answer: The Epi Team will be busy contacting many agencies, including hospitals, nursing homes, child care facilities, jails, schools, and other institutions.

Group Activity

The health director is concerned about how the lack of water pressure will affect institutional settings such as long term care facilities and correctional facilities. Choose either long-term care facilities or correctional facilities and describe what methods of communication the Epi Team will use to contact the facilities. Then, create a short message about the water contamination problem and appropriate actions to prevent waterborne disease transmission and other adverse effects.

Suggested answer: The Epi Team may use in-person visits, blast fax, email notices, personal phone calls, written memos, or other methods to communicate with long-term care facilities or correctional facilities. Examples of messages that may be included are:

• Facilities should follow written water action plans if available.

• All water for drinking, cooking, making ice, brushing teeth, and washing dishes should be boiled.

• Adding bleach to water may not sufficiently disinfect water for drinking. Some diseases such as Giardia and Cryptosporidium are not adequately killed by bleach disinfection.

• Potable water may be available through the American Red Cross and other relief agencies. For more information, please call (000)-000-0000.

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Question 7: Does the health director have the legal authority to order restaurants to close? If so, please describe this authority.

Suggested answer: There are 4 legal options for restaurant closure which are described below.

1) Immediate permit suspension due to an imminent hazard

This can only be done by an authorized agent of the state (an environmental health specialist). Many of North Carolina’s health directors are not authorized agents and therefore could not do this themselves. Instead they would need to have an authorized staff member do it or ask the NC Department of Environment and Natural Resources (DENR) to get involved.

2) Declaration of an imminent hazard and immediate abatement

This is not a permit suspension but rather just a declaration. This remedy allows the health director to immediately enter the restaurant and abate the hazard. An abatement could be, for example, locking the doors.

3) Public health nuisance order

The health director can issue this type of order but he or she must go to court to enforce the order, so it is probably not a timely option in an emergency situation.

4) County ordinance

Counties have the authority to adopt local ordinances that are triggered by the State of Emergency declaration (G.S. 14-288.12 and 288.13). These ordinances may be used to prohibit the operation of businesses or other places where people congregate, including restaurants. It should be noted that county ordinances do not automatically apply to cities within the county. Rather, the city must issue a resolution consenting to the county ordinance.

One example of this type of a county ordinance can be found in the Emergency Operations Plan (EOP) for Buncombe County. The Buncombe EOP states that an emergency proclamation, which is issued by the board of commissioners, can prohibit or restrict the operation of business establishments when reasonably necessary to maintain order and protect lives during the state of emergency (). This proclamation is separate from the original declaration of a state of emergency.

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Group Brainstorm

Because of existing relationships between county agencies (e.g. emergency management, public health, board of commissioners), the county found a timely and legal way to order restaurant closure. However, enforcing this ordinance will depend upon the relationship between the local health department and the business community.

Choose one person from your Epi Team to write answers on a flip chart. Then discuss the following question:

What can your health department do during non-emergency situations to develop positive relationships with restaurants and other members of the business community?

Suggested answer: There are many ways to reach out to the business community. The first is to provide education and build relationships during routine restaurant inspections. Assure restaurant owners that prevention of disease outbreaks is in their best interest, and public health will work together with them during outbreaks or other emergencies. Emphasize the role of the health department in maintaining the public’s health and remind business leaders that the public health community uses prohibitive measures (e.g. closing a restaurant) as a last resort.

In addition, one or more members of your Epi Team could offer to attend a meeting of the local chamber of commerce to discuss prevention and control of foodborne disease outbreaks, disaster preparedness, or pandemic influenza planning.

If there are large companies located in your area, it may be worthwhile to arrange individual meetings with representatives from those companies.

The health department may also encourage restaurant operators to participate in a food safety training program, such as ServSafe, which is offered by the NC Restaurant and Lodging Association.

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Question 8: Before you send health department staff to test water pressure in restaurants, what practical issues do you need to consider? Think about how these issues are addressed within the Incident Command System.

Suggested answer: Issues to consider are:

Work with the Operations and/or Planning Chiefs to determine:

• Number of restaurants that need to be visited;

• Names and specific location of restaurants (e.g. maps);

• Number of staff needed (recognize that environmental health specialists from other counties, or staff from other departments will need to be involved if there are not enough Epi Team members or environmental health staff to carry out the task);

• How staff will be trained to conduct the test;

• How staff will communicate test results to the restaurant owners/managers;

• Signs to post at restaurants that are ordered to close;

• Forms and supplies that should be brought to every restaurant visit;

Work with other ICS staff to determine:

• Safety for field staff (e.g. whether any personal protective equipment is needed to conduct tests, safety related to electricity in flooded areas). Work with ICS Safety Officer to address these issues;

• Communication between local health department and Emergency Operations Center;

• How to communicate the testing process to the media through the public information officer; and

• How to address potential problems and communications between the field inspectors and the Incident Commander or the Operations Section Chief.

Group Activity

You are almost ready to begin water pressure testing. First, you need to develop a plan for communicating with restaurant owners. You expect that some restaurant owners will be receptive to public health recommendations and requirements, while others may resent what they perceive as government interference. Choose one group member to be a recorder. As a group, create a short script that can be used by staff members conducting water pressure tests in local restaurants. Some ideas that you may want to include are:

• Potential public health threats resulting from contaminated water

• Explanation of the water pressure test

• Confirming the health department’s legal authority to order restaurant closure

• Consequences to restaurants refusing to close

Suggested answer: There are many possible scripts that could be written in this situation, but it should be as simple as possible. One example is shown below:

Hello, I’m here from the Springfield County Health Department. As you may know, the recent tropical storm disrupted the water supply in our area. Some businesses may not have adequate water pressure to operate safely. Having insufficient water pressure or no water at all significantly increases the risk of disease transmission and could cause a serious disease outbreak. Sufficient water pressure means enough pressure to properly flush toilets while the sink faucet is running.

To decrease the chances of an outbreak, we are testing the water pressure in all local restaurants by checking whether the toilets flush properly. Restaurants that fail the water pressure test will be ordered to close immediately by the health director. The health director has the authority to close restaurants during a state of emergency when there is a significant threat to human lives. If we have to close your restaurant, we will visit again to let you know when it is safe to reopen.

Question 9: Are there language and/or literacy issues that should be considered when preparing to meet with restaurant owners in the area?

Suggested answer: If restaurant owners might not speak English, it would be wise to translate the script above into appropriate languages and, when possible, have a translator accompany the environmental health specialists on restaurant visits. Owners should be provided with a phone number to call with questions if they do not understand the spoken or written materials, with telephone translation services available if needed.

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Question 10: Communicating with the public during a disease outbreak or public health emergency can be called “risk communication.” What are some guidelines for risk communication?

Suggested answer: “Crisis and emergency risk communication is the effort by experts to provide information to allow an individual, stakeholder, or an entire community to make the best possible decisions about their well-being within nearly impossible time constraints and help people ultimately to accept the imperfect nature of choices during the crisis.” (CDC Crisis and Emergency Risk Communication, 2002). One of the principles of risk communication is that the person conveying messages to the public or media is credible. Establish trust and credibility by conveying empathy and caring, competence and expertise, honesty and openness, and commitment and dedication.

Some tips from the Centers for Disease Control and Prevention’s Crisis and Emergency Risk Communication training () are:

• Be careful with risk comparisons

• Don’t over-reassure

• Sensitive syntax: put the good news in subordinate clauses (e.g. We’re not out of the woods yet, although we haven’t had any reported cases of waterborne diseases)

• Acknowledge uncertainty

• Give people things to do

• Stop trying to allay panic

• Acknowledge people’s fears

Remember: Be first, be right, be credible.

Although all Epi Team members should be familiar with risk communication, during an emergency, the ICS Public Information Officer should be responsible for communication with the media and the public. In a Unified Command situation the health department PIO will coordinate messages through the Joint Information Center, possibly in collaboration with the Local Health Information Team (LHIT).

Activity

People often have mistaken ideas about what is and is not acceptable to share with the public when engaging in risk communication. The table below lists several myths and realities related to risk communication. On your own, decide whether each statement is accurate, and write “myth” or “reality” next to the statement. Then discuss your answers as a group.

Risk Communication Myths and Realities

|Statement |Myth or Reality? |

|Telling the public about a risk is more likely to unduly alarm people than keeping quiet.| |

|You should pay as much attention to dealing with people as you do to explaining the data.| |

|You should not go to the public until you have solutions to health threats. | |

|If you listen to the public, you will devote scarce resources to issues that are not a | |

|great threat to public health. | |

|Everyone in the health department should understand the basic principles of risk | |

|communication. | |

|It is okay to provide technical information to the public. | |

Suggested answer:

Risk Communication Myths and Realities

|Statement |Myth or Reality? |

|Telling the public about a risk is more likely to unduly alarm people than keeping |Myth |

|quiet. | |

|You should pay as much attention to dealing with people as you do to explaining the |Reality |

|data. | |

|You should not go to the public until you have solutions to health threats. |Myth |

|If you listen to the public, you will devote scarce resources to issues that are not a|Myth |

|great threat to public health. | |

|Everyone in the health department should understand the basic principles of risk |Reality |

|communication. | |

|It is okay to provide technical information to the public. |Reality |

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Group Brainstorm

Often, after an outbreak investigation or a public health emergency, an Epi Team reviews the investigation in a “hot wash” or after-action review. The questions below are examples of questions that could be used in such a review. Choose one member of the Epi Team to record responses on a flip chart. As a group, discuss one or more of the following questions.

• What aspects of the water pressure investigation were successful?

• All public health emergencies present unique challenges. What characteristics of this emergency made it challenging?

• What areas of the investigation could have been improved?

• How does your local health department reach out to the local business community?

• If a similar water crisis occurred in your county, do you think that your Epi Team would be prepared to handle it?

• In this emergency, the county board of commissioners was supportive of the health director’s decision to close restaurants without sufficient water pressure. Describe the relationship between the local health department and the county board of commissioners in your county.

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[1] Centers for Disease Control and Prevention. Guideline for hand hygiene in health-care settings. MMWR Recomm Rep. 2002;51(RR16):1-44.

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Update – 2 pm, September 9th

To identify which restaurants must close and which may remain open, you need to determine whether each restaurant has sufficient water pressure. Your environmental health specialist develops a simple test to evaluate restaurant water pressure based on flushing a toilet. If there is enough water pressure to completely flush away a single piece of toilet paper while the sink faucet is running, the staff should be able to wash their hands and use the toilets safely, and the restaurant can remain open. If the single piece of toilet paper cannot be flushed, the restaurant should be ordered to close.

Update – 9 am, September 9th

The health department receives reports of many restaurants continuing to operate despite insufficient water pressure to maintain sanitation standards. Without good water pressure, staff cannot wash their hands, use the bathroom, or properly sanitize cooking/eating utensils, all of which violates North Carolina’s sanitation codes.

The board of commissioners is concerned about the risk of a disease outbreak due to poor sanitation in many restaurants. The county depends on tourism for a substantial amount of its annual revenue, and a disease outbreak from an unsanitary restaurant could adversely affect the tourist season. After getting approval from the board of commissioners, the health director decides to investigate the water pressure in every open food service establishment. He plans to require restaurants without sufficient water pressure to close.

Update – 3 pm, September 8th

The media is reporting that more people are eating at area restaurants due to the lack of residential water and continuing power outages. It is not clear whether restaurants are following the Boil Water Advisory. In addition, there is another problem related to the water supply. The water authority director reports a lack of pressure in some parts of the system. The lack of pressure is not consistent across the water system. In fact, there are areas where buildings on one side of a street have potable water at proper pressure while buildings across the street have no pressure.

Update – 10 am, September 8th

The health director has activated the Incident Command System and asked your Epi Team to fill various roles within the ICS structure. Based on your recommendations, a Boil Water Advisory is issued to protect people from the contaminated water (see below). However, initial environmental health inspection reports from fast food franchise restaurants indicate that many have no ability to boil water due to specialized microwave technology in their kitchens. Some, but not all, restaurants have brought in bottled water to serve to customers.

Background

On September 7th, a severe tropical storm dumped 13 inches of rain in a single day in your region causing severe flooding. There have been power disruptions, broken water lines, and 1 death. The board of county commissioners has declared a state of emergency.

You work at the local health department (Springfield County) and are a member of the Epi Team. Of particular concern to you and your team is a report from the water authority director that the main reservoir line for the county water supply has broken and there has been contamination in the system.

Conclusion – September 11th

You contacted all local media using blast fax and held a press conference at noon to announce the restaurant inspection process. At your invitation, the first restaurant inspection was broadcast live by a local TV station. Fortunately, the owner cooperated and the restaurant passed the water pressure test. Teams of 2-4 staff members inspected all area restaurants that had not already closed. About 85% of these open restaurants did not pass the water pressure test. Most closed voluntarily, but 20 were ordered to close based on the local county ordinance prohibiting restaurants to operate without sufficient water pressure. The job was completed in 2 days, and so far there have been no reported disease outbreaks. The flooding has receded, and business in the county is resuming.

Update – noon, September 9th

After consulting with leaders in the county’s Incident Command System, the health director discovers that the local Emergency Operations Plan (EOP) has language that will allow the county to close local restaurants. The EOP states that the board of commissioners can issue an ordinance that prohibits the operations of business establishments in order to protect lives during a state of emergency. The board is willing to make such a proclamation. However, you know that some restaurant owners will question the county’s authority to close restaurants.

Update

The ICS Public Information Officer (PIO) asks several members of the Epi Team to work with her to create a press release for the general public.

Reminder

As the facilitator, you are the only team member with the suggested answers to discussion questions and activities. Other Epi Team members have only the scenario updates and questions.

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Tropical storm hits Springfield County

September

10 a.m.- Health director activates ICS, Boil Water Advisory issued

10 a.m.- Health director activates ICS, Boil Water Advisory issued

Hurricane Phyllis hits Springfield County

September

3 p.m.- Water authority director reports lack of water pressure

3 p.m.- Water authority director reports lack of water pressure

10 a.m.- Health director activates ICS, Boil Water Advisory issued

Hurricane Phyllis hits Springfield County

September

9 a.m.- Health director decides to investigate restaurant water pressure

9 a.m.- Health director decides to investigate restaurant water pressure

3 p.m.- Water authority director reports lack of water pressure

10 a.m.- Health director activates ICS, Boil Water Advisory issued

Hurricane Phyllis hits Springfield County

September

September

2 p.m.- Environmental health specialist develops water pressure test

9 a.m.- Health director decides to investigate restaurant water pressure

3 p.m.- Water authority director reports lack of water pressure

10 a.m.- Health director activates ICS, Boil Water Advisory issued

Tropical storm hits Springfield County

9 a.m.- Health director decides to investigate restaurant water pressure

2 p.m.- Environmental health specialist develops water pressure test

3 p.m.- Water authority director reports lack of water pressure

10 a.m.- Health director activates ICS, Boil Water Advisory issued

Tropical storm hits Springfield County

September

September

September

September

Local health department staff test restaurant water pressure. Most restaurants close voluntarily.

Hurricane Phyllis hits Springfield County

10 a.m.- Health Director activates ICS, Boil Water Advisory issued.

3 p.m.- Director of Water Authority reports lack of water pressure.

9 a.m.- Health Director decides to investigate restaurant water pressure.

2 p.m.- Environmental Health Specialist develops water pressure test

Local health department staff test restaurant water pressure. Most restaurants close voluntarily

2 p.m.- Environmental Health Specialist develops water pressure test

9 a.m.- Health Director decides to investigate restaurant water pressure

3 p.m.- Water Authority Director reports lack of water pressure

10 a.m.- Health Director activates ICS, Boil Water Advisory issued

Hurricane Phyllis hits Springfield County

Tropical storm hits Springfield County

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