TOPOFF 3

1. TOPOFF 3 David Gruber Assistant Commissioner - NJDHSS Division of Emergency Preparedness and Response Joseph A. Barone Professor and Chair - EMSOP Chair - Executive Council – MEDPREP

2. Acknowledgements • Dave Gruber, Jim Blumenstock, Commissioner Jacobs • NJ OEM and State Police • Middlesex County Public Health Dept. • Connecticut Dept. of Public Health • Scotland Yard

3. TOPOFF 3 “Live” Video • VNN

4. New Jersey’s Overarching Objectives • 1. Administer effective and efficient prophylaxis distribution. • 2. Identify necessary staffing patterns for the “comprehensive” health care system. • 3. Exercise the disaster-declaration process. • 4. Examine the processes associated with quarantine and/or isolation orders. • 5. Explore the existing hospital capacities and related administrative systems. • 6. Examine continuity of government and business operations in public and private sectors.

5. Overarching Objectives (cont) • 7. Test the epidemiological processes and procedures to include the coordination of health care activities with law enforcement. • 8. Examine the in-State resources and Federal support for mortuary care. • 9. Evaluate the effectiveness of the EMAC. • 10. Assess existing mental health strategies for emergency workers and the public. • 11. Explore the coordination of intelligence andinvestigative authorities. • 12. Test the abilities of State and local governments and the private sector to conduct Risk Assessment, and manage a public information program.

6. Scenario • Planned covert release of Yersiniapestis in NYC 04 April • Operation is compromised prompting early release in NJ (2 April) • Linked to attack in New London • Linked to UK and Canada (direct/indirect)

7. Driving Routes

8. Total Cases of Pneumonic Plague 5000+ 2501-5000 1501-2500 501-1500 101-500 0-100 Day One: Monday 4 APR 05

9. Total Cases of Pneumonic Plague 5000+ 2501-5000 1501-2500 501-1500 101-500 0-100 Day Five: Friday 8 APR 05

10. T3 Main Events: Summary Local public health and health care partners • Reports of: • Suspect human cases • Animal die-offs CDC epidemiology team (on-site) NJDHSS Communicable Disease Service • Consultation • Epidemiologic assistance NJ Department of Agriculture CDC animal/vector team* NJ PHEL State Medical Examiner* • Death counts CDC NCID* • Lab testing Yersinia pestis confirmed* ~30,000 human plague cases (~30% mortality)* ~500 animal cases in rabbits and cats (~40% mortality)* * Notional play

11. Overview • Hospitalized 30,000+ • Fatalities 8000+ • All state acute care hospitals participate (FQHCs) • SNS received (Push package + VMI) • 22 PODs opened throughout state (actual), 400+ notional (LINCS agencies) • SEOC,HCC,CEOC open • Joint FBI Public Health Epi investigation • FBI takedown of bio-lab • NJSP takedown of safe house • JOC,JFO,JIC stand up

12. Now the fun stuff

13. The Full Scale Exercise • D-Day

14. The FSE

15. The 1st Response

18. Health Simulation Mannequins • Computer programmable training aids present physiological signs and symptoms associated with chemical, biological, nuclear, radiological, and explosive events and respond realistically to the medical procedures of responders • Supports overall trauma and mass casualty incident medical training • Will provide training to hospital, EMS, and non-hospital based healthcare professionals • Part of the State’s mass casualty incident training program (trainers will use all mannequins (10) at a single site to enhance the realism of a simulated mass casualty incident)

19. Operation Exodus The Evacuation of the “Healthy Sick” During TOPOFF 3

20. Operation Exodus • Transfer approximately 100 non-infected “healthy sick” patients from (8) eight hospitals/facilities in northern and central New Jersey • Evacuate these patients to other areas of the country via military aircraft in concert with NDMS

21. Operation Exodus • 12 “Strike Teams” were dispatched to (8) Eight Sending Health Care Facilities • (7) Seven Acute Care Hospitals • (1) One Long Term Care facility

22. Operation Exodus • 67 Ambulance Teams Participated: • 26 Licensed • 41 Volunteer • Staging : • Meadowlands • PNC Arts Center

24. Operation Exodus Loaded Stretcher Patients

25. Strategic National Stockpile Operations • Be careful what you don’t ask for (10M doses) • Just cause you got it, doesn’t mean you got it (Fed release) • Even when you finally get it, doesn’t mean you can use it (Cipro for plague) VMI focus How much is too much County/local ability to receive

26. Command, Control, Communications DHSS Medical Command Federal Cell HAN Admin EMS HCO&A Ops PIO IT Hospitals/FQHC/ LTC Human Services OITS RSS Public Health Off site ops Logistic (SNS/SSS) CDRS Epi Investigation Lab Lab Building Press BENS Public EMS Dispatch EMS TF DHS DEP Phone Gov office PODS LINCS AG HHS CDC JIC JOC FBI OCT Other Agencies/Orgs NJHA Hospitals EMS/General OEM EOC Govt. Agencies

27. T3 command and control structure– federal, state and local partners • Joint Operations Center (JOC)/ Joint Field Office (JFO) • Federal • DHS, FBI, DHHS, CDC • State • Attorney General’s Office, NJDHSS, OEM Federal/state • NJDHSS • Health Command Center (HCC) • Receipt/Stage/Storage Site (RSS) • Emergency Communication Center (ECC) • State Police Office of Emergency Management (OEM) • Emergency Operations Center (EOC) State Acute care hospitals County OEMs Local Local health departments

28. Command, Control, Management Observations • Federal officials in NJ–> roles unclear yet. . . • NJ made policy decisions without adequate intelligence input and federal perspective

29. Command, Control, Management Lessons learned • Need to identify all potential federal resources and attempt to optimize interface with federal agencies in advance • Need to ensure that state is involved in decision process regarding federal assets • Need to ensure that federal agencies acknowledge any state request with written documentation

30. Tuesday Evening: The Magic Begins • Conference call NJ, JFO, White House/HHS/DHS • Feds go postal • NJ says “yo”

31. NOTIONALITY, the Miracle Drug • Medications (10M doses before disease identified) • PODS (post offices) • People (15K NJ workers) • Medical professionals (25K surrounding states) • Medical Facilities (10K bed hospital)

32. Medication Delivery Observations • Ciprofloxacin and gentamicin lack FDA approval for treatment and prophylaxis of plague IND protocol for use; challenges in getting written Emergency Use Authorization • Adverse events routine reporting mechanisms through FDA

33. Medication Delivery Observations • Federally-operated PODs unclear whether operating under considerations (e.g., safety, facilitated crowd movement) as outlined in NJDHSS POD manual • No limits regarding antibiotics received from SNS but. . . • “Competition” with other states for limited resources

34. Medication Delivery Lessons learned • Need to consider alternate POD model(s) to accommodate mass non-targeted prophylaxis distribution (e.g., antibiotics to entire state during T3) • Arrangements with Departments of Corrections and Human Services, regarding confined living facilities • Partnerships with industry, “taking care of their own”; first responders

35. T3 Main Events: Summary 22 regional PODs, local health department assets 267 PODs, state assets* 189 PODs, federal assets* (e.g., U.S. Postal Service resources) > 400 PODs statewide* > 10 million doses of antibiotic prophylaxis distributed* * Notional play

36. Medical Surge Capacity Observations • NJ able to shift resources inter- and intra-state • Request for assets without numbers to support decisions Lessons learned • If alternate site facilities that cannot provide maximal levels of medical care are used, need to factor in ethical considerations when triaging patients to these facilities

37. Medical Surge Capacity Lessons learned • Need to consider limited resources and supplies, in face of “competition” with other states and within own state • Consider individual facility stockpiling of supplies (learn from “shortages”) • Decreased staff numbers and those with special skills/training “just in time” training • “Snow-day” model

38. Communications: Public Information Observations • Overall, consistent messages facilitated through: • Multi-agency coordination to adapt and respond to evolving event • Use of prepackaged materials (“shelf kits”) and regular communication with local agencies and hospitals

39. Communications: Public Information Observations • Overall, consistent messages facilitated through: • Multi-agency coordination to adapt and respond to evolving event • Use of prepackaged materials (“shelf kits”) and regular communication with local agencies and hospitals

40. Communications Lessons learned • Continue to ensure “one message” representing all agencies involved • Medication recommendations • Infection control and personal protective equipment recommendations (e.g., anticipate N95 v. surgical mask discussion also in pandemic influenza event) • Educational materials • Make sure that all assets are in the loop

41. Blood Center Operations Observations • American Association of Blood Banks Inter-organizational Task Force activated to address donor deferral and quarantine • National Blood Exchange emergency blood supply to NJ not all NJ blood centers apprised of process for receiving deliveries* * Notional play

42. What does it mean to go “RED”

43. Food Sector Activities Observations • Inter- and intra-state travel restrictions initially entertained during early phases of outbreak devastating effect on food distribution* • Decisions based on inadequate intelligence, need to do something * Notional play

44. Food Sector Activities Lessons learned • NJ Food Council’s Food Sector Advisory Committee: • Consider master plan to share sector resources, locations, inventory • Develop company-specific plans for retail store or distribution center regarding restoring product supply and staffing

45. Barone’s Observations • We are better prepared • Systems can get quickly overwhelmed • The little things will screw you up • There are lots of moving parts • Need to have processes in place and DRILL, DRILL, DRILL

46. Good Advice • Do no harm