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Tabletop Exercise

Tabletop Exercise. BT Epidemiologic Response Team Training September 25, 2003. Goals. BPH and BT epi response team members will understand: 1. The notification-call down procedure during a BT event 2. Who is in charge as a BT event escalates. 

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Tabletop Exercise

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  1. Tabletop Exercise BT Epidemiologic Response Team Training September 25, 2003

  2. Goals BPH and BT epi response team members will understand: 1. The notification-call down procedure during a BT event 2. Who is in charge as a BT event escalates.  Team roles in outbreak management and contact tracing as a BT event escalates. 4. Disease control, exposure assessment, and contact surveillance procedures

  3. Day 1 – Sept. 25, Thursday“The Unknown Powder”

  4. 6 pm: The State Police (SP) raid a meth lab in Harrison County and find 25 pounds of a powdered material. A person (Billie Bob) is arrested at the lab and is complaining of fever, cough, and has severe difficulty breathing. Billie Bob is a known drug dealer in Harrison County and is also affiliated with a local Harrison County white supremacy group. The local white supremacy group is part of a national organization that is under surveillance by the FBI and SP. The FBI learned several months before that the national organization had announced to its local groups that “democrat politicians and candidates for president and congress who oppose the current Bush administration’s anti-terrorist program are traitors and should be removed from office by any means necessary.”Billie Bob passed out while being taken to jail, was taken to the Harrison County Hospital ER and was admitted to the hospital with severe respiratory distress. The ER suspected pneumonia.

  5. 7:00 pm: SP calls Harrison County Health Department (HCHD) to get the powder tested. SP explains the ties between the local terrorist group and the national organization and the threat to the democratic party candidates and campaign workers. The FBI and SP assumed the powder was cocaine or another drug but wanted to rule out any biological agents. Hazmat team puts sample of powder in a bag and waits for SP to transport sample to state lab (OLS).SP secures the crime scene and notifies the FBI, which sends an investigation team. SP notifies Harrison County Sheriff who notifies local OES director. HCHD calls Bob White. Bob calls IDEP and asks about forms needed to send samples to OLS. SP transports powder to OLS.

  6. 9:00 pm: Radio, TV and newspaper reporters begin to call local HD and the IDEP on-call number – Ram Nambiar is the IDEP on-call duty officer.HCHD tells press that a meth lab was raided, an unknown powder was confiscated which was suspected to be drugs, and a sample of powder was sent to OLS for testing.

  7. Has a possible BT event occurred?What is the notification procedure? Who does Ram Nambiar, the IDEP on-call duty officer call? Who should be notified within BPH and outside BPH?Who is in charge of this incident? What is Ram’s responsibility? What is the IDEP/BT epi team role at this time? What information does IDEP want to know at this time? What does IDEP recommend/assure is happening at this time?What does Ram tell the reporter who calls the IDEP emergency number?

  8. Day 2 – Sept. 26, Friday“Powder is Y. pestis”

  9. 2 pm: Billie Bob goes into respiratory distress and dies. Hospital notifies HD. Cause of death is pneumonia – unknown cause. Blood and sputum samples sent to hospital lab for analysis.9.pm: OLS determines that the sample of powder from the meth lab is Y. pestis ground to a 1-5 um particle size. OLS notifies Dr. Cathy Slemp, IDEP, SP, FBI, and HCHD. Raja is the IDEP on-call duty officer and notifies Dr. Bixler who calls Loretta Haddy (State Epidemiologist). Harrison County Hospital sends Billie Bob’s specimens to OLS. The HCHD Health Officer (HO) calls IDEP and tells Raja that he is notifying all HCPs and ERs to watch for plague cases and is sending an alert to Radio and TV stations announcing the incident. HCHD wants to know if BPH is going to send out an alert.

  10. 9:30 pm: HCHD notifies its local OES director who notifies WVOES. 10:30: WVOES convenes a conference call with BPH, SP, FBI, HCHD, and Harrison County OES Director. 11:30 pm: The WVEOC is activated. Governor appoints a task force. Governor makes an announcement to the media.

  11. Has a possible BT event occurred? Who sits in on the WVOES conference call?Who is in charge at BPH? Who is on the response team at BPH?What is the IDEP/BT epi team role at this time?What is the BPH response now?

  12. Day 3 – September 27, Saturday“The Outbreak”

  13. 8 am: BPH advises LHDs to notify all their ERs and HCPs to report all cases with clinical signs and symptoms consistent with a working case definition. BPH advises all LHDs to notify IDEP of any cases via the IDEP emergency call number.What is the working case definition at this time?

  14. 6 am-12 noon: ERs at Huntington Hospital, CAMC, Ruby Memorial, and Wheeling Hospital report 40 cases of fever, cough, and signs of pneumonia to their LHDs. All cases present with signs of bloody sputum, malaise, nausea, vomiting, and abdominal pain. One-two cases at each ER additionally presented with painful swollen lymph nodes. Plague is suspected at ERs. CAMC: 10 Huntington: 10 Ruby 12 Wheeling 8

  15. 12-1 pm: HO’s in Cabell-Huntington, K/C, Monongalia, and Wheeling-Ohio County HDs meet with their nurses and sanitarians to decide on strategy. -  HDs report cases to IDEP on-call duty officer as they are reported to the HDs.-   HOs and head nurses prepare alerts for media. HOs call BPH and ask if BPH is putting out an alert. -   Nurses call all ERs, primary care providers, and urgent care clinics, and notify by FAX all HCPs to notify HD of any new cases meeting the case definition.- HOs and nurses visit hospitals to investigate cases.

  16. Are symptoms consistent with plague? Is this an outbreak of plague?Does BPH and LHDs put out an alert before cases are confirmed by OLS? How is alert coordinated with HDs?Who is in charge at BPH? Who is on the outbreak management team? What are state, local, and regional epidemiologist roles and responsibilities?Does BPH send epi teams to counties to assist in the investigation? Who goes into the field and who stays at outbreak management headquarters?

  17. How do field personnel communicate with field teams? Do we tell LHD nurse teams to wait before proceeding to interview cases until BPH/IDEP teams arrive? What instructions does BPH/IDEP have for LHD nurse teams who will be interviewing cases? (e.g., line lists of cases, disease prevention and control objectives, line list of contacts, antibiotics for plague treatment and post-exposure prophylaxis, the epi investigation protocol to be followed such as hypotheses to be addressed, study design, number and type of cases and/or noncases to be interviewed, questions to be asked, forms to be used for data gathering etc)How is contact tracing and surveillance coordinated? What are the state, local, and regional epidemiologist responsibilities at this time?

  18. 1:00 pm: BPH establishes an incident command center in DSDC conference room with an emergency call-in number for HDs. All HDs are notified of the call-in number. BPH sends plague protocol to all HDs. Hospitals ask local HDs where to send specimens for testing. HDs call BPH command center for consultation. What specimens should be collected for testing? What labs do testing for Y. pestis? Who is ensuring that clinical specimen are taken and submitted to the lab on all suspected cases? Who will track the lab results?

  19. 2 pm: CDC announces that similar outbreaks of flu-like symptoms consistent with plague are occurring in 20 other states. A total of 1000 cases have been reported in the US from 5 am through 3 pm. State and local health departments are on their own. CDC is concentrating on the larger metropolitan areas. CDC develops a working case definition and notifies states. BPH notifies HDs of the new working case definition: fever and cough or who had direct contact with a probable or confirmed plague case since September 19-25.

  20. 2:10 pm: HDs assume a plague outbreak and determine that local hospitals and pharmacies have enough doses of streptomycin, gentamycin, doxycycline, and ciprofloxacin for treatment of cases and post exposure prophylaxis of contacts.Hospitals send clinical specimens to OLS.Do hospitals begin treatment of cases and LHDs begin prophylaxis of household contacts prior to lab confirmation? IDEP advises HDs to collect information on cases travel and activity schedules during previous 7 days using the IDEP forms 3B-C in order to identify common exposures. HDs are also advised to identify all contacts according to the protocol using forms 2A-E.

  21. All 40 cases reported in the 4 hospitals satisfied the case definition. Forms 3A-C were completed on all 40 cases and sent to IDEP and IDEP found the following common activities:- 2 cases had ties with the terrorist cell - 1 case had no known ties with the terrorist cell or democratic rallies or county headquarters.

  22. - 28 of the 40 cases had attended a democratic campaign rally in their county 4 days ago (Sept. 23) [Charleston (8), Wheeling (4), Huntington (8), and Morgantown (8) ] - 30 of the 40 cases had attended a statewide democratic rally in Charleston 3 days ago (Sept. 24).- 37 of the 40 cases had worked in democratic field headquarters in these counties within last 7 days (Sept 20-27).- 37 of the 40 cases had attended either a local rally or the state rally or both.- 10 had attended a Marshall football game in Huntington and 10 had attended a WVU football game in Morgantown on Sept. 20.

  23. BPH/IDEP provides this information to incident command at the WVEOC (SP, FBI, WOES) and local HDs. WVOES notifies local OES directors and local police.2:30 pm: Incident command centers are set up at each county with SP, Sheriff, fire, local OES, and public health represented.3 pm: FBI and local law enforcement task force interrogate the 2 cases with known ties to the Harrison County white supremacy group and the two cases admitted that they participated in exposing democratic campaign workers to Y. pestis. They would not disclose where the exposure took place. Incident command centers turn to public health for further investigations.

  24. Law enforcement task force reports that approximately 2,400 people attended local democratic rallies in 8 counties 4 days ago (about 300 in each county) and about 5,000 people attended the state rally in Charleston 3 days ago. Head counts were available from the state democratic committee rally organizers but no list of names were available.

  25. What type of antibiotics do we need? How many people possibly need antibiotics? How long do we have to provide treatment of cases and post-exposure prophylaxis of exposed and contacts?Who will check for availability of antibiotics in state? Is the SNS activated yet? Are there enough doses of antibiotics available in the regions around the hospitals for treatment of cases and post-exposure prophylaxis of exposed people and case-contacts?How do we assess source of exposure more specifically? (e.g., hypotheses, study design, who should be interviewed, questions to be asked, forms to be used, who will collect and evaluate the data, how are the investigations to be managed, what are the state and local roles and responsibilities).Should environmental samples be taken, and if so where and who collects them?

  26. 10 pm: – OLS identifies Y. pestis in clinical specimens from Billie Bob. This is first indication of Y. pestis in a patient. Do we do anything differently in our investigation now?

  27. Day 4 – Sept. 28, Sunday“More Cases”

  28. 8 am-4 pm: 60 new cases of fever, cough, and pneumonia like symptoms appear at ERs: 5 deaths among the 40 cases reported yesterday.2 pm-10 pm: OLS confirms Y. pestis in clinical specimens from 20 cases reported on day 3. Volunteers are recruited by LHDs to begin case-contact identification and surveillance. Antibiotics are requested from state.

  29. The FBI and state and local law enforcement task force reports that three plague cases all had ties with the local Harrison County terrorist cell. Members of the cell emptied one small plastic bag of Y. pestis into the main hallways of each county democratic rally in 8 counties (those counties in which cases were reported) and in 3 main hallways at the state rally at the Charleston Civic Center.The local HDs interviewed cases and identified all case-contacts. The total number of cases and case-contacts are as follows (each case exposed 5 personal contacts and 20 health care workers and visitors at each ER):

  30. County CasesContactsK/C 17 105Cabell-Huntington 25 145Monongalia 25 130Wood 8 60Jackson 5 45Beckley/Raleigh 5 45Wheeling 13 85Marshal 5 45Total: 100 660

  31. What are team assignments (state and local roles) for exposure investigation, surveillance of exposed and case-contacts, ordering and distributing antibiotics, and providing PEP to exposed and case-contacts? Do we need to order from SNS? What is the projected number of cases?

  32. Day 5-7 – Sept. 29-31Monday-Wednesday“More Cases”

  33. 8am-4pm: OLS confirms Y pestis in remainder of 20 cases reported on day 3 and 20 cases on day 4. 3 deaths. 40 new cases appear on day 5, 20 on day 6, and 10 on day 7. The total number of cases and contacts for surveillance are as follows:County CasesContactsK/C 27 175Cabell-Huntington 30 170Monongalia 35 225Wood 18 130Jackson 10 70Beckley/Raleigh 10 70Wheeling 18 130Reynolds 10 70Harrison 5 45Total: 170 1085

  34. Does the increasing number change state/local teams and roles?Does local HDs need assistance in setting up clinic for prophylaxis of contacts?How many doses do we need? How many more cases could there be? Does BPH need to request the SNS? Do we need more volunteers than we have on state and local teams for contact tracing and surveillance? Do we need to change our strategy for managing contact surveillance? Where do we get more volunteers?

  35. Lessons Learned?

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