After Action Report Form - CIDRAP



AFTER ACTION REPORT

Coordinated Multi-State

Pandemic Influenza

Tabletop Exercise

Wednesday, November 15, 2006

Wide Open Spaces

Public Health Collaborative

Colorado, Kansas, Nebraska, Wyoming

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Executive Summary

A global pandemic influenza outbreak represents one of the most catastrophic threats to the U.S. public health system. In the 20th century, three major pandemics were caused by the emergence of several new influenza A virus subtypes that resulted in over 600,000 deaths in the United States (U.S. Centers for Disease Control and Prevention [CDC], 2005).

New influenza “A” virus subtypes, similar to the ones that caused the pandemics of the 20th century, are likely to emerge in the 21st century as well. Medical advances and public health preparedness efforts have improved the nation’s abilities to respond to a pandemic influenza emergency even as dramatic increases in global travel and the demand for poultry have made the United States more vulnerable to such threats.

In preparing for such a threat, public health agencies must work closely with a number of partners, including emergency management agencies, law enforcement agencies, elected officials, and healthcare agencies and providers.

This tabletop exercise was intended to test the relationships between partners, in response to a pandemic flu emergency.

The exercise was led by a facilitator who presented participants with chronological segments of a scenario separated by a series of discussion points that enabled participants to describe how they would respond to the evolving scenario at isolated points in time. The exercise facilitator was aided by a note taker and a local resource person who was responsible for assisting or backing up the facilitator.

The exercise relied on a “forced decision-making” framework, which requires participants to make key decisions at each discussion point after they have had time to consider the scenario and the information provided to them at a specified point in time.

The exercise focused on five broad issue areas:

• Surveillance and Epidemiology

• Command, Control, and Communications

• Risk Communication

• Resource Coordination

The exercise consisted of three sections:

• Unfolding Situation--Decisions and Responses; A new influenza A subtype has been spreading from person to person in countries in Southeast Asia and initially materializes in the United States in Florida. Participants are required to discuss the steps they would take to prepare for the disease before it spreads to their jurisdiction.

• Later Developments--Decisions and Responses; he disease spreads to Nebraska. Participants are required to discuss everything from how they would initially detect the disease’s presence in their community, to how they would mitigate the disease’s effect on their community, to how they would manage, distribute, and administer a vaccine for the disease.

• Debriefing and Self-Evaluation; Participants reflect on the exercise experience and discuss strengths and areas for improvement. Participants are then asked to identify the three most important gaps that they identified and to outline concrete, short-term plans for beginning to address these gaps.

Participants were encouraged to develop short - and long-term plans for all of the gaps identified.

Major Strengths of the exercise included:

• The participants of all agencies involved demonstrated an excellent ability to recognize the difficulties of dealing with a pandemic flu emergency.

• The participants demonstrated a positive attitude and ability to recognize and react to shortfalls in planning as they were uncovered.

• Each state understood its own reporting system and had an excellent understanding when to include state Heath and Human Services System.

• Local Health Departments were comfortable with surveillance communication across state lines, on the local level, and stated they would be conducting emails and phone calls with cross border partners as situations developed.

In addition, several successes of this exercise should be recognized, among them:

• This was the first major exercise of this nature that included Colorado, Kansas, Nebraska, and Wyoming.

• It was a major, and positive, undertaking to gather this many partners on a video conference to deal with pandemic flu emergency issues.

Through the exercise, several opportunities for improvement in the ability to respond to a pandemic flu incident were identified:

• It was unclear how states would communicate with one another on the state level and who would be the lead in sharing information.

• There was no clear command structure in place across state lines. The exercise was designed to be played without a declared emergency, or EMAC assistance. Without this declared emergency at the state level, it would be very difficult to coordinate the activities of the four player-states. Each state should determine what would realistically take place in this scenario at their respective state and national levels to determine what support would be available.

• It was clear that, while informal communication between the states was excellent, there is a lack of formal agreements on how health districts should deal with pandemic flu issues across their states borders. It is recommended that each state should revisit the scenario, to explore the possibility of working with local, state and federal agencies in an emergency.

Part 1: Exercise Overview

This exercise was a teleconference table top with multiple locations in each of the participating states of Colorado, Kansas, Nebraska and Wyoming.

Jurisdiction Information:

The Mid-America Alliance and the Nebraska Emergency Management Agency (NEMA) participated in an administrative and facilitative role.

Exercise Name: Wide Open Spaces, Coordinated Multi-State Pandemic Influenza

Type of Exercise: Tabletop

Duration: 3 hours

Exercise Date: November 15, 2006

Sponsor: Mid-America Alliance

Focus: Response

Location: Multiple locations in Colorado, Kansas, Nebraska and Wyoming

Participating Organizations:

Public Health:

Colorado

Larimer County Department of Health and Environment

Weld County Department of Public Health and Environment

Northeast Colorado Health Department

Kit Carson County Health and Human Services

Lincoln County Public Health

Cheyenne County Public Health

Prowers County Public Health

Kiowa County Nursing Service

Baca County Nursing Service

Kansas

Cheyenne County Health Department

Hamilton County Health Department

Morton County Health Department

Sherman County Health Department

Stanton County Health Department

Nebraska

Southwest Nebraska Public Health Department

Panhandle Public Health Department

Two Rivers Public Health Department

Wyoming

Albany County Public Health Response Coordinator (Region 3)

Laramie County Public Health (Region 7)

Region 7 Laramie, Goshen and Platte Counties

Fire/HazMat:

Colorado

Union Colony Fire and Rescue Authority

Burlington Fire Protection District

Kansas

Morton County Fire Department

Emergency Medical Services (EMS):

Colorado

Kit Carson County Emergency Medical Services

Weld County Paramedic Service

Kansas

Stanton County Emergency Medical Services

Morton County Emergency Medical Services

Wyoming

American Medical Response (AMR)

Medical:

Colorado

Kit Carson County Memorial Hospital

High Plains Community Health Center

North Colorado Medical Center

SE Hospital and Long Term Care Center

Sterling Regional Medical Center

Poudre Valley Hospital

McKee Medical Center

Keefe Memorial Hospital

Estes Park Medical Center

Bent County Coroner

Kit Carson County Coroner

Kansas

Morton County Hospital

Stanton County Hospital

Goodland Regional Medical Center

Nebraska

Community Hospital

Tri Valley Hospital

Dundy County Hospital

Perkins County Hospital

Wyoming

Platte County Hospital

Goshen County Hospital

Albany County Hospital

Carbon County Hospital

Cheyenne Regional Hospital (Formerly United Medical Center)

Communications/Dispatch:

Colorado

Kit Carson County Communications Center

Prowers County Communications Center

Weld County Communications Center

Kansas

Stanton County Sheriff Office

Wyoming

WDH Emergency Operations Coordination Center

Law Enforcement:

Colorado

Burlington Police Department

Kit Carson County Sheriffs Dept

Larimer County Sheriff Office

Kansas

Stanton County Law Enforcement

Wyoming

Laramie County Sheriffs Dept

Cheyenne Police

Wyoming Highway Patrol

Emergency Management

Colorado

Greeley Emergency Management

Lincoln County Office of Emergency Management

Logan County Office of Emergency Management

City of Loveland Emergency Management

Larimer County Emergency Management

Kit Carson County Office of Emergency Management

Prowers County Office of Emergency Management

Yuma County Office of Emergency Management

Colorado Division of Emergency Management, SE Field Staff

Kansas

Cheyenne County Emergency Management

Sherman County Emergency Management

Stanton County Emergency Management

Morton County Emergency Management

Hamilton County Emergency Management

Nebraska

Furnas County Emergency Manager

Nebraska Emergency Management Agency

Wyoming

Albany County Emergency Management (Region 3)

Laramie County Emergency Management (Region 7)

Universities/School Districts

Colorado

University of Northern Colorado

Colorado State University

Nebraska

University of Nebraska

Wyoming

Department of Education

Public Works, other local agencies

Colorado

Department of Social Services, ESF 6, SE Region

Kit Carson County Health and Human Services (Social Services Branch)

Larimer County PIO Consortium

Kansas

Southwest Kansas Health Initiative

Stanton County Commissioner

Morton County Commissioner

Morton County PIO

Nebraska

Mid-America Alliance

Wyoming

VA Infection Control

VA Safety/Security

Laramie County Community College Epidemiology Students

MENTAL HEALTH

Colorado

Centennial Mental Health

Policy and Government

State

Colorado

Colorado Department of Public Health and Environment

Kansas

Kansas Department of Health and Environment

Nebraska

Nebraska Department of Health and Human Services

Wyoming

Wyoming Department of Health

Wyoming National Guard

Office of Homeland Security

Health and Human Services

Department of Transportation

RETAC/LEPC, etc.

Colorado

Plains-to-Peak RETAC

Northeast Region Homeland Security

Kansas

Southwest Kansas Regional Homeland Security

Nebraska

South Central Regional LEPC

Exercise Overview: This exercise was designed to offer an opportunity to discuss a four-state response to pandemic influenza; as well as simultaneously review local and regional Pandemic Influenza plans in Colorado, Kansas, Nebraska and Wyoming.

It was designed to assist in identifying planning components and public health response structures that may impede or confound the ability of bordering counties to assist or work with one another.

Since epidemiological events can be long term and require numerous agencies, a multi-disciplinary approach is required to plan for and respond to these health threats. It was also intended to give those participating an opportunity to become informed about on-going planning efforts and will be used to assist in building relationships on an interstate level.

Exercise Evaluation: The focus of the exercise was to enable participants to assess current response capabilities of a pandemic or epidemiological incident requiring communication and coordination of Risk Communications among border counties of Kansas, Colorado, Nebraska and Wyoming, identifying strengths and weaknesses, and identifying future training needs. The exercise focused on key local emergency responder coordination, critical decisions, and the integration, where appropriate, of interstate communication. Evaluators were positioned at all exercise locations to assist in the overall identification of issues.

Evaluators: Evaluators worked as a team with Site Facilitators. They did not interact with players. Evaluators recorded events and ensured documentation was submitted for review and inclusion in the After-Action Report (AAR)/Improvement Plan (IP). Evaluators did not interfere with the integrity of the exercise or players. All questions raised during the exercise were to be addressed by the Site Facilitator.

Handbooks and Evaluation Forms: An F/E Handbook was used to guide the conduct and evaluation of the exercise. Evaluation forms were provided to the evaluators to assist in capturing the highlights of this exercise. The Exercise Evaluation Guides (EEGs) were used and referred to in case questions or discrepancies arose.

Chapter 2: Exercise Goals and Objectives

The following were the major exercise goals:

• Policy issues affecting public health response either positively or negatively on an interstate level

• Roles of participating agencies in a Pandemic

• Gaps in preparedness and coordination

• Identification of related training/learning needs

The following were the exercise objectives as outlined in the EXPLAN for this exercise. It should be noted that the format of this EXPLAN is from the Homeland Security Exercise and Evaluation (HSEEP) Toolkit. The objectives in this EXPLAN are formatted in such a way as to suggest an operations based exercise (functional or full-scale). The objectives in the EXPLAN were very ambitious. Typically in a tabletop exercise one would expect to focus on a limited number of objectives, perhaps three to seven.

From the document titled: Coordinated Multi-State, Pandemic Influenza, Tabletop Exercise, EXERCISE PLAN (EXPLAN), Final Version 4.0 10/31/2006, Prepared by: Dawn James, RN/MSN-C:

Major Exercise Goals and Objectives

Note: Exercise Objectives are linked to the CDC Pandemic Influenza work plan guidance.

• In addition to the major goals and objectives listed below it is hoped the following will be discovered:

• Policy issues affecting public health response either positively or negatively on an interstate level

• Roles of participating agencies in a Pandemic

• Gaps in preparedness and coordination

• Identification of related training/learning needs

Goal A: Evaluate tactical communications capabilities across

state lines (between public health and partner entities

via HAN, Fax, e-mail, radio, etc.)

Tactical Communication Objectives:

I. Planning

WOS Table Top Objective 1:

Bordering agencies (public health officials, hospitals, emergency managers, MD officers, etc) will clearly and effectively identify how to communicate with each other (fax, email, phone, etc) designating key local authorities and stakeholders engaged in the planning and executing of local pandemic response.

Performance Measure(s):

1. Results of post-exercise evaluation of the resource directory by border agencies who utilized the directory to communicate information of public health importance with border counties, including information on status of school and public event closures.

2. Results of post-exercise evaluation of bordering agencies understanding of key local and bordering agency authorities and stakeholders engaged in pandemic influenza response.

CDC 1A::CTb: Plans must delineate accountability and responsibility for key local authorities and stakeholders engaged in planning and executing specific components of the operational plan (e.g., identification, isolation, quarantine, movement restriction, healthcare services, emergency care, mutual aid and school closure).

________________________________________________________________

II. Detect and Report

WOS Table Top Objective 2:

Bordering agencies will notify state agencies of information received across state lines in a timely manner.

Performance Measure(s):

1. Local public health agencies will discuss processes for notifying the state following a receipt of a call about an event that may be of urgent public health consequence. Discussion will include the turn-around time for such communication.

CDC 3A, 4A: Decrease the time needed to detect and report an influenza outbreak with pandemic potential.

CDC 4A, 1: Support exchange of essential information before and during an influenza pandemic. Coordinate procurement and placement of technology communication systems that, based on gap analysis of requirements versus existing capabilities, are compliant with PHIN preparedness Function Area Partner Communication and Alerting.

WOS Table Top Objective 3:

Bordering agencies will follow their state agencies terms and conditions for the use of secure communications channels of each state’s Public Health Information Network or Health Alert Network.

Performance Measure(s):

1. Local agencies will understand and discuss the distribution guidelines as defined by alerts issued through state health alert networks in the exercise.

2. Local agencies will discuss the process for seeking appropriate approval and for sharing the information in the alert with the bordering jurisdictions.

CDC 4A, 2: Have access to interoperable information systems that support the initial identification and that provide situational awareness of possible pandemic influenza outbreak in compliance with PHIN Preparedness Functional Area Early Event Detection.

a) Receive, triage and send case or suspect case disease reports 24/7/365.

b) Receive health related data from multiple data sources to monitor, quantify and localize aberrations to normal data patterns

WOS Table Top Objective 4:

In the event of a public health emergency that extends beyond the border agency’s jurisdiction and extends across state-lines, the border agency will be able to identify how to share reports across jurisdictions and multiple-levels of public health ensuring restricted information is only available to intended recipients.

Performance Measure(s):

1. Local agencies will discuss the process used to define and count confirmed probable or suspect cases and the best means to share information on counts.

2. Local agencies will discuss the process used to collect and share reports received on information obtained from multiple data sources including but not limited to veterinary systems, school absenteeism reports, hospital utilization data, nurse call lines and over-the-counter drug sales.

________________________________________________________________

III. Medical Surge

WOS Table Top Objective 5:

Bordering agencies (public health officials, hospitals, emergency managers, MD officers, etc) will clearly and effectively communicate with each other (fax, email, phone, etc) about the operating status of hospitals.

Performance Measure(s):

Local agencies will identify the key person or position responsible for the dissemination or receipt of information on the status of the county hospitals and discuss the turn-around time for the communication.

CDC 6A, 1B: Exercise communication systems, plans and procedures to ensure that hospitals, health care systems and public health inform the community about the operating status of hospitals and the triggers for sending a person to the hospital

________________________________________________________________

IV. Isolation and Quarantine

WOS Table Top Objective 6:

Bordering agencies will communicate on criteria used for isolation and quarantine and methods used to support service and monitor those affected by containment measures.

CDC 6B, 6: Develop and exercise an operational plan for isolation and quarantine that delineates the following:

a) The criteria for isolation and quarantine

b) The procedures and legal authorities for implementing and enforcing these containment measures, and

c) The methods that will be used to support, service, and monitor those affected by these containment measures in healthcare facilities, and other settings

WOS Table Top Objective 7:

Bordering agencies will develop or utilize their understanding of the procedures and legal authorities for implementing and enforcing containment measures in local and bordering jurisdictions.

Performance Measure(s):

1. Results of a post-exercise evaluation on each bordering agencies understanding of the procedures and legal authorities for implementing and enforcing containment measures in local jurisdictions and bordering jurisdictions.

CDC 6B, 7: Develop and exercise operational plan to implement various levels of movement restrictions within, to, and from the jurisdictions.

WOS Table Top Objective 8:

Bordering agencies will share plans and policies on movement restrictions within, to, and from jurisdictions.

Performance Measure(s):

1. Local agencies will identify the key individual or position responsible for coordinating movement of restrictions to and from jurisdictions.

CDC 6B, 7: Monitoring compliance with non-pharmacological interventions including tracking persons in quarantine.

WOS Table Top Objective 9:

Bordering agencies will share information on level of compliance with non-pharmacological interventions.

Performance Measure(s):

1. Local agencies will discuss process for sharing reports on level of compliance with quarantine orders.

2. Local agencies will discuss process for sharing report on school closures and cancellation of events (social distancing).

________________________________________________________________

V. Emergency Public Information and Warning

WOS Table Top Objective 10:

Bordering agencies will utilize and share methods of nontraditional vehicles of information dissemination to the public, partners and stakeholders in neighboring jurisdictions.

Performance Measure(s):

1. Local agencies will discuss nontraditional vehicles of information dissemination that can be used to share information across jurisdictions.

2. Local agencies will share knowledge of nontraditional vehicles of information dissemination used within their jurisdiction.

CDC 6D, 4: Identify additional and non-traditional vehicles of information dissemination to the public, partners and stakeholders.

Goal B: Explore risk communications messaging on an interstate level

________________________________________________________________

I. Medical Surge

WOS Table Top Objective 11:

Bordering agencies (public health officials, hospitals, emergency managers, MD officers, etc) will identify ways to clearly and effectively identify communicate with each other (fax, email, phone, etc) on the specific patient referral processes and how this will be conveyed to the public.

CDC Performance Measure(s):

1. A four state resource directory outlining resources (forms, specific contact information, multi-agency procedures, etc)

CDC 6A, 1B: Exercise communication systems, plans and procedures to ensure that hospitals, health care systems and public health inform the community about the operating status of hospitals and the triggers for sending a person to the hospital

_____________________________________________________________

II. Isolation and Quarantine

WOS Table Top Objective 12:

Bordering agencies will build trust by learning how to develop “One, clear, consistent” message that will be shared with border communities to provide reassurance and information regarding an event.

CDC Performance Measure(s):

1. The communication time to respond to the public and provide honest information.

2. Preprinted/ developed communication materials disseminated to all the partners.

CDC 6B, 5: Disseminate information from public health sources on:

a) Routine infection control (e.g., hand hygiene, cough/sneeze etiquette)

b) Pandemic influenza fundamentals (e.g., signs and symptoms of influenza, modes of transmission)

c) Personal and family protection and response strategies (e.g., guidance for the at-home care of ill students and family members)

WOS Table Top Objective 13:

Bordering agencies will identify and share existing community mitigation plans and policies on implementing social distancing across state lines and how that information will be disseminated to the public.

CDC Performance Measure(s):

1. The time to issue an isolation or quarantine order

2. Time an individual is retained for medical evaluation while determining need for isolation

3. Public health officials recommend school closure when pandemic influenza case counts reach pre-determined levels.

CDC 6B, 8: Inform citizens in advance what community mitigation measures may be used in the jurisdiction (e.g. tabletop exercises)

________________________________________________________________

III. Emergency Public Information and Warning

WOS Table Top Objective 14:

Bordering agencies will discuss how to establish Joint Information Centers (JIC), and discuss the development of a Joint Information System that would serve a complex interstate Incident Command response incorporating multi-agency partners (fire, hospitals, EMS, public health, tribal nations, etc), in order to serve as a centralized communication hub to achieve consistent and efficient information flow.

CDC Performance Measure(s):

Time to issue critical health message to the public about an event that may be of urgent public health consequence

Time to distribute educational materials (fact sheets, FAQ’s, etc) to the public.

CDC 6D, 1 and 2: Exercise communication plans with an emphasis on:

a) Coordination with response partners and tribal nations

b) Rapid provision of public health risk information and recommendations

c) Addressing stigmatization, rumors and misperceptions in real time

d) Surge capacity for public information, media operations and spokespersons

e) Procedures to secure resources to activate the public information and media operation during a public health emergency around the clock if needed for a minimum of 10 days. Prepare supporting materials for public health issues that are unique to an influenza pandemic such as issues of isolation, social distancing, and public health law.

WOS Table Top Objective 15:

Bordering agencies will make non-traditional partnerships a community priority (post offices, local business, special needs populations, etc)

CDC Performance Measure(s):

1. Time to issue critical health message to the public about an event that may be of urgent public health consequence.

CDC 6D, 4: Identify additional and nontraditional vehicles of information dissemination to the public, partners and stakeholders

Goal C. Discuss Incident Command complexity when standing-up multiple Department Operation Centers (DOC ‘s) in a non-governor declared emergency requiring interstate cooperation by bordering counties.

WOS Table Top Objective 16:

Identify and discuss the implementation of the type of command and control that would have the greatest functionality across state lines.

WOS Table Top Objective 17:

Identify how border counties will report to one another and collaborate with one another in a complex incident command structure.

CDC PERFORMANCE MEASURE(S)

Critical Task(s):

1. Develop, exercise and improve operational plans for pandemic influenza at the state and local level. Plans must:

a) be compliant with National Incident Management System and include Incident Command System (ICS)

b) delineate accountability and responsibility for key local authorities and stakeholders engaged in planning and executing specific components of the operational plan (e.g., identification, isolation, quarantine, movement restriction, healthcare services, emergency care, mutual aid and school closure)

c) address integration of state, local, tribal, territorial, and regional plans across jurisdictional boundaries

2. Formalize agreements that address communication, mutual aid, and other cross-jurisdictional needs with neighboring domestic and/or international jurisdictions sharing an international border with Canada or Mexico (e.g., city-state-tribal collaboration arrangements or city-state-province/state collaboration arrangements)

3. Ensure that legal authorities for executing the operational plan, especially those relevant to case identification, isolation, quarantine, movement restriction, healthcare services, emergency care, and mutual aid, are transparent to all stakeholders

4. Identify and communicate to all stakeholders the authority responsible for declaring a public health emergency at the state, local and tribal levels and for officially activating the pandemic influenza response plan

Chapter 3: Exercise Events Synopsis

Expectations

• No agency is fully prepared for this type of public health emergency.

• Open and honest dialog and feedback are encouraged throughout the exercise.

• Participants should feel free to ask questions of one another and challenge each other’s assumptions.

• No one will be singled out or punished for what they say during the exercise.

• You will act on what you learn

Unfolding Situation - Decisions and Responses

Scenario Part I

July of 2006, an outbreak of unusually severe respiratory illness is identified in a small village in southern China. At least 25 cases have occurred, affecting all age groups; 20 patients required hospitalization, 5 of which have died to date. Surveillance in surrounding areas is increased, and new cases begin to be identified throughout the province. Viral cultures collected from several of the initial patients are positive for type A influenza virus. The isolates are sent to the World Health Organization (WHO) Collaborating Center for Surveillance Epidemiology and Control of Influenza at the Centers for Disease Control and Prevention (CDC) in Atlanta, for further characterization. CDC determines the isolates are type A H7N3, a subtype never before isolated from humans.

This information is immediately transmitted back to the Ministry of Health in China and throughout the WHO network. CDC, in collaboration with WHO, dispatches a team of epidemiologists and laboratory personnel to further evaluate the outbreak and disseminates a Health Alert Network (HAN) advisory notifying clinicians and U.S. state health departments to be on the alert for patients with severe respiratory illness and a history of travel to the region of Asia where the human cases occurred. Isolates of the H7N3 virus are sent to the WHO Collaborating Centers and to the U.S. Food and Drug Administration (FDA), so that work can begin to produce a reference strain for vaccine production. Influenza vaccine manufacturers are placed on alert. The outbreak caused by the novel influenza virus begins to make headlines in every major newspaper and becomes the lead story on major news networks. Key U.S. government officials are briefed on a daily basis as surveillance is intensified throughout Southeast Asia and the Pacific Rim.

Given the international spread of the new virus among people in Southeast Asia, the window of time before this virus reaches the United States will be short because of (1) international travel and (2) transmissibility of influenza during the asymptomatic phase of infection

Facilitator Probes:

Decisions to be made:

1. What are the specific key tasks that public health agencies and their healthcare partners need to carry out to step up surveillance in a way commensurate with the threat?

2. What command structure is appropriate at this point, e.g., a formal Incident Command System (ICS), informal ICS, other, or no official structure at this point?

Decision 1:

Probes for public health agency partners:

• What actions should be taken to engage partners in stepped-up surveillance efforts?

• How will any prior planning for surveillance be utilized in this situation?

• What guidance should be provided to healthcare partners regarding their surveillance efforts?

• How will the local public health agency coordinate surveillance and reporting with partners?

• What methods of communication will be used (phone, fax, email etc.)?

Probes for healthcare partners:

• What responsibilities related to surveillance do hospitals and front-line physicians have?

• What expectations do healthcare providers have for public health agencies?

• What type of surveillance should be established in emergency rooms?

• What is the role of hospitals and laboratories during stepped-up surveillance efforts?

Probes for all partners:

• How would stepped-up surveillance be different from normal influenza-surveillance activities?

• How is information on cases systematically collected and aggregated?

• Who will communicate what information to labs?

• Should anything be done to ensure that existing response systems are working correctly?

Decision 2:

Probes for if a formal ICS is activated:

• Who is responsible for activating ICS protocols?

• Who is in charge of the ICS?

• What partner agencies will be involved in the ICS?

• How will the ICS be used to manage the response across partner agencies?

Probes for if a formal ICS is not activated:

• Is there a defined trigger for when it is appropriate to establish a formal ICS?

• How will all healthcare partners be involved in coordinated decision-making pre-ICS?

• What communication channels will be used across partner agencies?

Probes for either decision:

• What partner agency is in charge of coordinating and leading stepped-up surveillance efforts?

• What partner agency is responsible for reviewing global, national, regional, and local influenza-activity trends to identify emerging problems?

Scenario Part 2

Mid-August, human cases of H7N3 have been reported in Hong Kong, Singapore, South Korea, and Japan. Although cases are reported in all age groups, young adults appear to be the most severely affected, and case-fatality rates approaching 5%. Public unease grows because vaccine is not yet available and supplies of antiviral drugs are severely limited.

In early September, human cases are identified in the United States. CDC reports the H7N3 virus is isolated from ill airline passengers arriving from Hong Kong and Tokyo in Los Angeles, Honolulu, Chicago, and New York. State and local agencies are asked to intensify influenza surveillance, but no clusters have been identified outside of these major cities. Vaccine manufacturers are asking when the vaccine seed viruses will be available.

Decisions to be made:

1. Should the command structure you decided on in the previous discussion remain in place, or is a different structure now appropriate?

2. What specific key tasks should state agencies engage in to prepare for the outbreak before it reaches Nebraska?

Facilitator probes:

Decision 1:

If the command structure will change:

• What specific changes are appropriate?

• What is different now that requires the change?

• What partner agency is in charge of the new structure?

If the command structure will not change:

• Why is no change necessary?

• By what means and how often should partners communicate with one another?

• What will be the “structure” for this communication across state lines?

Probes for either decision:

• What guidance or directives should the public health agency give to healthcare agencies?

• How will the public health agency work with healthcare agencies to manage the “worried well”?

• How will the states coordinate these efforts to speak as one voice?

•

Decision 2:

Probes related to planning for surge capacity:

• How should agencies coordinate planning?

• What should be done to coordinate the supply of scarce medical supplies?

• What should be done to plan for future needs related to critical infrastructure?

• What can be done to anticipate and limit the number of “worried well”?

• Are partners considering plans to establish nontraditional healthcare facilities?

• What should be done to plan for needs related to staffing at state agencies?

• Is it appropriate to think about recruiting and training volunteers at this time?

• Are there healthcare professionals who could be identified to help in an emergency?

• Are there legal issues (licensing and liability issues, ethical issues, issues related to isolation and quarantine) that need to be addressed before the disease reaches the local area?

• How will HHS guidelines for priority groups to receive antiviral drugs be translated into practice?

Probes related to disease prevention:

• What activities should partner agencies engage in related to disease prevention?

• What non-pharmacological approaches to disease prevention are appropriate at this time?

• What should be done to deal with the limited supply of antiviral medications?

• Is it appropriate to begin pre-identifying priority groups for antiviral prophylaxis?

The national media continue to cover pandemic flu stories.

The local press contacts Health and Human Services to inquire about what the health agency and its healthcare partners are doing to prepare.

Decisions to be made:

1. From each state: Which state agency has primary responsibility for communicating with the media?

2. What are the key things that need to be done to ensure proper management of risk communications across partner agencies AND across state lines?

3. What are the key messages the public should be told at this point in time?

Decision 1:

If the public health agency is chosen:

• What person(s) within the public health agency will be responsible for directly communicating with the media?

• How will the public health agency involve other partner agencies in risk-communication planning?

If an agency other than public health is chosen:

• Why is public health not the agency responsible for communicating with the media?

• What person(s) will be responsible for communicating directly with the media?

• How will risk-communication messages be coordinated across partner agencies?

Decision 2:

Probes related to management of risk communication:

• Should partner agencies wait for the press to contact them, or should they be proactive and schedule regular press conferences?

• What channels should be used to get consistent messages out to the public?

• Are there special strategies that need to be considered to communicate with minority groups or special-needs populations?

• How often should partner agencies communicate with the media and in what manner?

• JIC?

Decision 3:

Probes related to risk-communication messages:

• What do you anticipate are the questions partner state agencies will most likely need to answer?

• How can risk-communication messages be designed to minimize public anxiety and fear?

• What guidance should risk-communication messages contain to try to limit large numbers of worried well from overwhelming the system?

Later Developments - Decisions and Responses

Scenario Part 3

On Thursday, October 19, 2006, the Sherman County Health Department receives information about a severe influenza-like illness among two staff members of the NW Technological College.

1. What key epidemiological steps should be used to follow up with potential cases and their contacts?

2. What changes should your agencies be making at this point?

Facilitator probes:

Decision 1:

Probes for the public health agency:

• What other information would the public health agencies like to know? For example: Where are the patients now? What tests have been done?

• Should the public health agency give any advice to the ICP and the hospital? For example, should public health offer advice about the use of personal protective equipment?

• What other infection-control strategies might be necessary at this point?

• How would public health staff confirm whether patients were sick with the pandemic flu strain?

• What is the appropriate level of follow-up for each potential case (e.g., chart review, telephone interview, interview in person, contact tracing)?

• What samples need to be collected, and who should collect those samples?

Probes for all partners:

• How is the clinical information handled and managed?

• How is it collected, aggregated, and shared across partner agencies?

• What laboratory or laboratories are appropriate to use?

• How are clinical samples packaged and sent to laboratories?

Decision 2:

Probes for the public health agency:

• Should any social-distance protocols be implemented at this time?

• How will these protocols be enforced and by whom?

• Should potential cases and their contacts be quarantined?

• What legal authority does the public health agency have to take such steps as closing schools and involuntarily quarantining individuals?

Probes for all partners:

• Is antiviral prophylaxis for contacts of patients appropriate at this point?

• How should decisions be made about allocating the scarce supply of antiviral medications?

• Who should administer antiviral medications?

• What non-pharmacological disease-control strategies should be implemented?

• What is the best way to manage scarce medical supplies and staff?

It is reported the pair did have a history of travel to Orlando, FL on October 14-16 where they attended an Accredited Respiratory Care Educational Conference. Specimens were being collected for viral testing and being sent to the Kansas State public health laboratory. After further investigation, the public health nurse at Sherman County discovers the staff members were actively involved in promoting the awareness of the new respiratory care program that would be available in 2007 at the college. As part of the promotion, they visited with family members attending the Family Day on October 16 at the college. They were in close contact with family members from 33 Counties who attended the informational session with hands-on activities.

• A global influenza pandemic is confirmed by WHO.

• The outbreak spreads throughout our four-state area with some counties citing early estimates of around 10% of the population falling ill and a 3% case fatality rate. Hospitals and outpatient clinics in the surrounding areas have reached capacity.

•

• All state agencies across our AREA are reporting staffing shortages. Functioning with only 70% of existing staff.

• A significant number of doctors and nurses and other critical infrastructure staff are also unavailable, either because they are ill or have not come to work.

• Staff, who are available to work, report that they are exhausted and need more rest time.

• Local pharmacies, health care providers, and hospitals across the AREA are reporting shortages of antivirals as well as diminishing supplies, especially of ventilators, gloves, masks and lab supplies.

Decisions to Be Made

• What strategies will partner agencies use to manage large staffing shortages?

• What essential functions must remain in place for:

• Public health agencies

• Health care partners (especially hospitals)

• Civil society

• What strategies will partner agencies use to implement the surge capacity plans outlined earlier?

Facilitator probes:

Decision 1:

Probes for all partners:

• How do partners determine how many staff are available without double-counting?

• What staff plans are in place to rotate critical staff to avoid complete exhaustion?

• How will unmet hospital-staffing needs be addressed?

Decision 2:

Probes for the public health agency:

• What public health services must remain in place?

• How might public health assist hospitals to maintain their essential functions?

Probes for healthcare partners:

• What hospital services must remain in place during the emergency?

• Should elective surgeries and other elective procedures be canceled? Who makes these decisions?

• What other critical healthcare services must remain in place?

• What decisions need to be made about adopting alternative standards of care--for example, shifts in nurse-to-patient ratios?

Decision 3:

Probes for the public health agency:

• Should Strategic National Stockpile (SNS) or other antiviral stockpiling be implemented?

• How is the public health agency working with healthcare facilities and hospitals?

Probes for healthcare partners:

• In what ways should hospitals revise their existing triage procedures?

• Who makes these decisions?

Probes for all partners:

• How are surge-capacity plans coordinated across all partner agencies?

• In what way are volunteers utilized, and who is in charge of managing volunteers?

• How and where will nontraditional medical sites be established, managed, and staffed to treat patients?

• How will people isolated at home receive necessary food and medical supplies?

• What partner agency will manage the increasing numbers of dead bodies?

More information on alternative standards of care can be found in AHRQ (2005).

(More scenario information… if needed)

• The CDC begins shipment of vaccine across the country. It has identified health care providers, elderly, and people with chronic diseases as priority populations.

• Two doses of the vaccine will be required.

• [Local area] receives an initial shipment of [insert a number between 5,000 and 200,000] doses to vaccinate high priority groups.

• More vaccine is expected in the coming weeks

Facilitator probes:

Decision 1:

If the public health agency is chosen:

• How will public health work with its partner agencies to manage and distribute the vaccine?

If an agency other than public health is chosen:

• Why is public health not the agency responsible?

• How is the vaccine received and then distributed?

Decision 2:

Probes for all partners:

• How do you decide who gets the vaccine?

• People who have not been ill?

• Healthcare workers only?

• Families of healthcare workers?

• EMS?

• Law enforcement?

• Others involved in critical infrastructure?

• How will the HHS Pandemic Influenza Plan influence your decision-making about who receives vaccines?

Decision 3:

Probes for all partners:

• How would vaccine inventories be monitored? How would such events as adverse medication side effects be monitored?

• How would individuals who received the first dose be followed up for their second dose?

• How does the vaccine get administered?

• Who is going to give it?

• Where will it be given?

• What recordkeeping plans will be put into place?

• What plans would be put in place to recall people who need a second dose?

• How do you protect the supply of vaccine?

• How would HHS guidance get implemented? For example, what procedures would be used to verify vaccine-eligibility forms?

Chapter 4: Analysis of Mission Outcomes

Surveillance:

THE IDEAL: All agencies involved in the response:

• Articulated a clear, unified plan for stepped-up surveillance efforts across state lines. (Yes, within their respective states…however, across state lines this was more difficult.)

• Understood their respective role in stepped-up surveillance efforts. (yes)

• Articulated how their surveillance efforts dovetailed with other partner agencies. (yes)

• Demonstrated the ability to effectively collect, share, and evaluate surveillance information in a timely manner. (Yes, the ability to do this effectively across state lines should be further explored.)

Epidemiology

THE IDEAL: All agencies involved in the response:

– Demonstrated the ability to frame relevant follow-up questions based on surveillance findings. (Yes)

– Launched a unified epidemiologic investigation of an intensity and aggressiveness commensurate with the public health threat at each stage. (Yes)

– Demonstrated ability to apply epidemiologic methods in crafting successive queries as hypotheses were developed, rejected, or came into greater focus. (Yes)

Command, Control & Communication

THE IDEAL: All agencies involved in the response:

– Set up a command structure that was commensurate with the threat during each stage of the exercise. (No. The agencies saw a need for a Joint Information Center, but were reluctant to put together a command structure to support it.)

– Identified an agreed-on leader. (No)

– Demonstrated the ability to effectively communicate with one another. (Yes, especially at the local level.)

– Presented a unified response plan that was coordinated seamlessly across partner agencies. (Without a command structure in place… this would be difficult.)

Risk Communications

THE IDEAL: All agencies involved in the response:

– Worked together to carefully develop and disseminate risk communications messages. (Yes)

– Identified a cross-agency public information leader and spoke to the media with “one voice.” (Did not identify a leader, but did attempt to speak with one voice)

– Articulated a plan to proactively communicate with the media. (Yes, but again, this would be difficult without a command structure)

– Developed clear and consistent messages across agencies based on facts. (Yes)

– Demonstrated ability to effectively communicate with vulnerable communities. (Yes)

Surge Capacity

THE IDEAL: All agencies involved in the response:

– Were able to identify the availability of resources for emergency transport, emergency department care, beds, ventilators, and staff. (It was noted that this could be done with in the states, but difficult to do across borders)

– Developed plans to share resources. (It was noted that direction from CDC would be helpful on this issue)

– Had clear relationships with one another, including memorandums of understanding and pre-established plans for dealing with limited staff and resources. (Clear relationships were established, again plans -exist in each state, but plans that deal with issues across state lines do not.)

Disease Prevention and Control

THE IDEAL: All agencies involved in the response:

– Considered strategies to balance competing needs for more information versus the need for rapid action to control the disease from spreading. (Yes)

– Possessed knowledge of, or were readily able to access, indications and contraindications for vaccination or prophylaxis. (Yes)

– Applied available guidelines and developed a rational process to determine who should receive vaccination/prophylaxis. (Yes, this was discussed)

Conclusions:

The biggest challenge in this exercise was the attempt to deal with an incident as large as pandemic influenza without a declared health emergency. This scenario would quickly overwhelm local resources. Without an emergency declaration it would be difficult to coordinate a response.

While the local districts should be applauded for determining how they could work together across state lines, without a declaration, there must be guidance at the state and national level with plans and procedures for a response of this nature.

Local Health Districts should review and test existing plans and procedures with their local and state emergency managers. These local and state emergency managers have existing emergency operations plans that would assist the local health districts in their response. These operations plans should be explored in future exercises.

The goals of this exercise were very ambitious. Exercises are designed to test existing plans and procedures and the level of training that personnel have in regards to those plans. In this case, each state has plans and procedures for their respective state, and the personnel were well trained to those plans and procedures. The main challenge in this exercise was: there is no “four-state plan”. It will be up to this partnership to determine if such a plan is needed, or if existing local, state and federal health plans meet the needs of the partnership.

While this exercise did expose some gaps in preparedness, this partnership has come a long way in identifying planning and training needs. This exercise was a bold move toward better preparedness in dealing with a pandemic influenza outbreak. This partnership will, no doubt, continue to explore ways to prepare for such a scenario.

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