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2. Measles Tabletop Hospital & Public Health Joint Exercise [Insert Date]
3. Purpose of the Exercise Provide participants an with opportunity to evaluate current response concepts, plans, & capabilities for a response to a biological event.
Joint exercise with hospital & public health players.
Focus on incident command for the hospital & LHD, as well as epidemiological investigations & PODs.
Public information strategies will be critical to the overall response effort.
4. Scope of the Exercise This exercise emphasizes:
The role of the Hospital Incident Command System.
The role of local public health, including ICS, epidemiological investigations, & Points of Dispensing.
5. Objectives of the Exercise Validate abilities to do the following:
Implement ICS & establish the command structure to manage a biological event.
Develop a crisis & emergency risk communications message to the media, public, partners, & key stakeholders in response to a biological event.
6. Objectives continued Identify the necessary plans, policies, & procedures to implement & support communications interoperability.
Identify the necessary plans, policies, & procedures for coordinating & conducting epidemiological surveillance & investigation in response to a biological event.
Identify the necessary plans, policies, & procedures for requesting SNS assets in response to a biological event.
7. Participants - Players Players respond to the situation presented based on expert knowledge of response procedures, current plans, procedures, & insights derived from training.
8. Participants - Observers Observers support the group in developing responses to the situation during the discussion.
Observers are not participants in the moderated discussion period.
9. Participants – Facilitators Facilitators provide situation updates & moderate discussions. They also provide additional information or resolve questions as required.
Key planning committee members may assist with facilitation as subject matter experts (SMEs) during the tabletop exercise.
10. Participants – Evaluators Evaluators are assigned to observe & evaluate certain objectives during the exercise.
Their primary role is to document players’ discussions, including how & if those discussions conform to written & established procedures.
11. Exercise Structure Multimedia, facilitated tabletop exercise.
Players will participate in 3 distinct modules:
Module 1: Incident notification
Module 2: Initial Response
Module 3: Ongoing Operations
12. Exercise Structure Each module begins with an update that summarizes the key events occurring within the simulated time period.
Following the updates, participants review the situation & engage in functional group discussions of appropriate response issues.
13. Exercise Guidelines This is an open, low-stress, no-fault environment.
Varying viewpoints, even disagreements are expected. Agree to disagree.
Respond on your knowledge of current plans, capabilities, & insights derived from training.
You may use only existing assets.
14. Exercise Guidelines Decisions are not precedent setting & may not reflect your organization’s final position on an issue.
Issue identification is not as valuable as suggestions & recommended actions that could improve response & preparedness efforts. Problem-solving efforts should be the focus.
15. Assumptions & Artificialities The scenario is plausible. Events occur as they are presented.
There is no “hidden agenda,” nor any trick questions.
All players receive information at the same time.
16. Module 1:
Incident Notification
17. DAY 1 Saturday, Sept. 4 9-year-old Amberli wakes up complaining to her mother, Eve, that her throat is very sore & she feels chills.
Eve takes Amberli’s temperature. The result is 101şF.
Amberli becomes very upset to learn that due to her temperature, she cannot spend the night with her friend, Isabella.
18. Day 1 Continued Amberli begs her mother to take her to the doctor and see if the doctor could prescribe something so she can still go to Isabella’s house.
The pediatrician’s office was closed until Tuesday, September 7 due to the Labor Day weekend.
19. Day 1 Continued Eve takes Amberli to the Emergency Department.
The hospital ED seemed unusually busy. Eve & Amberli wait for 1 ˝ hours.
An ED nurse triages Amberli and sends her back to the waiting room for another hour.
20. Day 1 Continued After 2 hours of waiting, the ED physician evaluates Amberli and sends her home with the following instructions:
Take Tylenol every 4-6 hours until fever subsides.
Keep well hydrated.
Get plenty of rest
21. Day 1 Continued Eve gives Amberli Tylenol around noon & checks her temperature an hour later.
Since her temperature is only slightly elevated (99.2), Eve allows Amberli to go to her friend’s house.
22. DAY 2 Sunday, Sept. 5 Amberli is allowed to attend church at the Community Church & Sunday school.
23. DAY 4 Tuesday, Sept. 7 With the help of Tylenol, Amberli’s fever seems to wax & wane throughout the weekend. She also develops a cough and a runny nose.
Eve, who has a very important business meeting this morning, decides that Amberli is well enough to go to school.
24. Day 4 Continued Mid-morning, Amberli starts to feel chills again.
Amberli’s teacher sends her to the school nurse.
The school nurse takes Amberli’s temperature, which reads 102.5şF.
25. Day 4 Continued The nurse notifies Eve that Amberli is sick & she needs to pick her up.
Eve tells the school nurse that her meeting will be finished in 15 minutes.
Amberli waits for her mother in the main school office for the next 30 minutes.
26. Day 4 Continued When Eve arrives at the school, she notices that Amberli does not look as well as she did when she dropped her off just a few hours earlier.
Eve also notices a rash around Amberli’s hairline.
Concerned, Eve takes her to Amberli’s pediatrician, Dr. Jergen.
27. Day 4 Continued Dr. Jergen is able to see Amberli 45 minutes after they arrive at his office.
He rules out scarlet fever on the basis of a negative rapid test for Streptococcus.
Dr. Jergen looks at the rash, but he does not appear overly concerned.
Eve and Amberli go home with the same recommendations they received at the ED on Saturday.
28. DAY 5 Wednesday, Sept. 8 Amberli’s symptoms worsened overnight.
The rash has started to progress down to her neck. Her temperature is now at 104şF.
Eve quickly takes her back to the ED. Amberli is admitted to the hospital for observation due to her worsening symptoms.
29. Day 5 Continued Dr. Jolly, the attending physician and an infectious disease specialist, asks Eve several questions about Amberli:
Does she have any allergies?
Has she been on any new medications?
Has she been around anybody else who has been ill?
Eve responds with a “No” to these questions.
30. Day 5 Continued Eve states that Amberli is a sweet, average 9-year-old who plays soccer, goes to Sunday school, spends time with her friends, volunteers at the soup kitchen, & likes to travel with her mom.
Eve asks Dr. Jolly if it’s possible that she picked up something during a trip to Switzerland. Eve had a business trip & thought Amberli would have fun traveling with her.
31. Day 5 Continued As Eve relays some travel stories, Dr. Jolly reviews Amberli’s chart & notices there is no indication that Amberli is up-to-date on her MMR vaccinations.
Based on the clinical presentation and the lack of immunity, Dr. Jolly orders the collection of blood specimens for measles antibody testing.
32. Day 5 Continued Dr. Jolly informs the Infection Control Nurse (ICN) at the hospital of the suspect measles case.
The ICN immediately notifies the local health department and speaks to the Communicable Disease (CD) Nurse.
33. Day 5 Continued After reporting to and consulting with the KDHE Epidemiologist On-Call, the CD Nurse recommends collecting a nasopharyngeal swab for culture and initiates an epidemiologic investigation.
The CD Nurse informs the local health department Administrator and the Public Information Officer of the suspect measles case.
34. Module 1: Key Issues Day 1- Saturday
Amberli develops fever and visits Emergency Department.
She goes to a friend’s house later that day.
Day 2- Sunday
Amberli attends church & Sunday school.
35. Module 1: Key Issues Day 4- Tuesday
Amberli goes to school & is sent home with a fever.
Amberli is taken to her pediatrician after her mother notices a rash along her hairline.
The pediatrician rules out scarlet fever, and rapid test for Streptococcus is negative.
36. Module 1: Key Issues Day 5- Wednesday
Amberli is running 104şF temperature & rash has spread.
Amberli is taken to the ED & admitted to the hospital.
Amberli’s vaccination history is unknown.
Amberli recently traveled to Switzerland.
The doctor informs Infection Control Nurse of suspect measles.
37. Moderated Discussion
Facilitator & Players: Refer to your Situation Manual for questions for discussion.
38. Module 2:
Initial Response
39. DAYS 5 & 6 Wed. Sept. 8–Thurs. Sept. 9 Additional testing is performed at the Kansas Health & Environmental Laboratories (KHEL) in Topeka.
The serology result is positive IgM for measles.
The culture also is positive.
40. Days 5 & 6 Continued The CD nurse interviews Eve using the case investigation form in the measles Disease Investigation Guidelines.
Eve verifies that Amberli has never received an MMR vaccine due to a religious exemption.
Eve explains that she & Amberli visited Switzerland & arrived back in the U.S. 10 days ago.
41. Days 5 & 6 Continued Eve also says that Alexa, Amberli’s 11-month-old sibling, is the only other household contact.
However, Alexa & Amberli spend a lot of time with Eve’s grandmother, Susan.
Alexa also attends a home daycare.
42. Days 5 & 6 Continued Eve lists the places that Amberli had been 4 days before & 1 day after the onset of rash:
ED during her initial visit on Saturday
Isabella’s house on Saturday
Church & Sunday School on Sunday
School on Tuesday
Pediatrician’s office on Tuesday
ED again on Wednesday
43. DAY 7 Friday, Sept. 10 The LHD verifies that Eve received 2 MMR vaccinations as a child.
Eve’s mother, Susan, is not considered susceptible because she was born before 1957.
44. DAY 7 Friday, Sept. 10 Alexa is excluded from attending daycare.
All the other daycare attendees & the daycare provider are up-to-date on their MMR vaccinations.
45. Day 7 Continued The epidemiologic investigation is ongoing to identify additional cases & susceptible contacts among the many persons Amberli may have exposed.
Amberli’s sister, Alexa (11 months old), has developed a fever & a rash.
46. Next 3 Weeks Continued Ricky (10 years old) was in the ED waiting room with Amberli on Saturday when she first went to the ED.
He develops a measles-like rash 10 days later.
47. Next 3 Weeks Continued Ricky then infected:
A hospital health care worker, Tammy (age 35). Rash onset was 12 days after exposure.
A LHD staff member, Eleanor (age 41). Rash onset was 11 days after exposure.
A school mate, Megan (age 10). Rash onset was 8 days after exposure.
48. Next 3 Weeks Continued Contacts are identified among persons exposed by Amberli, Alexa, & Ricky:
Staff & patients at the hospital ED
Relatives & friends
Church members
School mates
Pediatrician’s office
Vaccine statuses of all contacts are assessed.
49. Next 3 Weeks Continued Increased awareness in the community increases the number of cases being reported as suspect measles.
The LHD is flooded with calls from the public & local news reporters regarding a measles outbreak.
Panic is beginning to set in.
50. Next 3 Weeks Continued The MMR vaccination status of the hospital health care worker, Tammy (age 35), was unknown.
She has been excluded from work & developed symptoms while on leave.
Other susceptible hospital staff members who were exposed have been excluded per guidelines.
51. Next 3 Weeks Continued A KS-HAN alert is received with key info:
Overview of the original case.
KDHE acknowledges that most, if not all, of local & regional assets have been utilized. Calculations should assume you will use any local & regional stockpiles first.
KDHE expects to receive shipments of post exposure vaccine & immune Globulin (IG) today, 9/20/10.
Each county must make requests by 9/22/10, so KDHE can work out its shipping schedule.
Refer to KS-HAN Alert (mock).
52. Next 3 Weeks Continued The LHD has administered all post exposure vaccine & immune Globulin (IG) in local & regional stockpiles.
You expect to receive additional supplies through your request to the State.
The LHD is busy getting ready for a POD clinic.
The LHD needs to prepare a public message regarding the POD.
53. Module 2: Key Issues Days 5 & 6 – Wednesday & Thursday
The lab confirms Amberli has measles.
Amberli has not received an MMR vaccination due to religious preferences.
Contacts include Amberli’s mother & infant sibling, and potential exposures at the hospital, her friend’s house, church, school, & pediatrician’s office.
54. Module 2: Key Issues Day 7 – Friday
It is confirmed that Amberli's mother received an MMR vaccination as a child.
The infant sibling is excluded from daycare. She also begins to develop a fever and rash.
55. Module 2: Key Issues Over the following 3 weeks, primary & secondary contacts become infected.
Boy from the hospital ED
Classmate of the boy
Hospital worker
LHD staff member
56. Module 2: Key Issues Community awareness begins to increase. The LHD is flooded with calls from the public & media.
KDHE issues a HAN alert with key information about the outbreak.
The LHD is assessing local & regional caches to initiate setting up a POD for mass vaccination.
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58. Module 3:
Ongoing Operations
59. Conclusion of Events All cases, including Amberli, are on the road to recovery.
An additional 10 cases were identified within the community.
Aggressive surveillance & follow-up, vaccination clinics, & educational messages were successful in stopping the outbreak.
60. Module 3: Key Issues 11 cases, including the original patient, were infected & recovered.
Efforts for surveillance, mass vaccination, & public education were successful.
61. Exercise Scenario Concluded
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63. Exercise Wrap-Up Participant Feedback Summary
Page 1: Completed individually. Provide to the Point of Contact completing the AAR/IP for your facility.
Page 2: Completed individually. Submit evaluations of exercise design to the Exercise & Training Coordinator at KDHE Bureau of Public Health Preparedness.
64. Exercise Wrap-Up Hot-Wash
Group discussion
After Action Review & Improvement Plan
Submit to Director of Evaluation & Administration at KDHE Bureau of Public Health Preparedess
65. Cait Purinton-Day
Exercise & Training Coordinator
Kansas Department of Health & Environment
Bureau of Public Health Preparedness
(785) 296-1984
cpurinton-day@kdheks.gov
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