Bio-Security 2007 Table Top Exercise in JAPAN Lessons from the Exercise

1. Bio-Security 2007 Table Top Exercise in JAPAN Lessons from the Exercise Presented by Mitsuyoshi Urashima MD, PhD, MPH

2. CDC WHO: Japanese Embassy in foreign countries overseas Central Government (observer) Foreign Affaires*2 Police*4 M. Health*1 Central Defense*3 Transport*7 Infectious disease*10 Business Airport Aviation Railroad Co Subway Co Amusement Park Hotels Pharmaceutical Co. Travel agency Department store etc Local Government*8 Public health center*9 scene Hospitals First responders Fire Police Media 200 personnel: Not only LE/PH but Others

3. Central Government (observer) Defense Prefecture Tokyo PH center Fire Dep Prefecture Chiba PH center Fire Dep Police Phone Foreign Affairs Phone Tokyo Disney Land Hotel Travel agency Control Room Live Broadcasting M of Health NIID Airport Aviation Transport Messengers monitoring all rooms by video rrding School Hospital C No notice Real role play Player driven Inject Live broadcasting Media Hospital B Pharmaceutical Co Hospital A Interview On the same floor 15 small rooms: Each organism 1 large room: Monitor and Control

4. Scenario: opened to participants after exercise and before workshop SARS virus: CDC category C CO2 incubator for Cell culture Clean bench Earth Underground TUSK on the Earth Culture media Anthrax: CDC category A

5. Arrival: Two tourists were infected here and each visited hospital A and hospital B. Departure: One tourist was infected here and got sick in Singapore.

6. This fish market was a target by terrorist. Taking antibiotics, another taking sprayed anthrax

7. Many workers got inhalation anthrax by exposure to the spores at the fish market. Moreover, a person who never visited the fish market got intestinal anthrax by eating fish traded there.

8. Injecting Information Ministry of Foreign Affairs Sep 17: Anti-globalization activist: plan for demonstration by extremists during G8 Tohyako summit, by the Japanese Embassy in Germany (telegraph) FALSE Sep 19: Extremists: possibility of bioterrorism in Japan, by the Japanese Embassy in Afghanistan (telegraph)FALSE Sep 23: Vials containing SARS virus derived from super spreader kept in a research institution were stolen: still possibility, by the Japanese Embassy in Singapore (telegraph)TRUE Sep 23: A Japanese tourist admitted to hospital due to severe respiratory disease, by the Japanese Embassy in Singapore (telegraph) TRUE If these information were passed to Ministry of Health, it could be easier to suspect SARS but not avian flu.

9. Injecting Information National police agency Sep 17: The same threatening letters by genuine defense/animal liberation fighters: “TUSK on the Earth” were sent to three fish food restaurants: Warning blast: The cancellation stamp was Toronto, Canada. TRUE Sep 20: Threatening letter to sports stadium: Which was confirmed as cat copy of “TUSK on the Earth”. FALSE Sep 22: Advance warning : Death to the Minister of Agriculture, Director-General of Fisheries Agency, and Minster of Environment to each major media by fax. TRUE

10. CDC WHO: Avian Flu:Considering up-phase from 3 to 4 in Indonesia Japanese Embassy in foreign countries overseas Threat of terrorism Robbery of SARS vials Central Government (observer) Foreign Affaires*2 M. Health*1 Police*4 Central Defense*3 Transport*7 Infectious disease*10 Business Airport Aviation Railroad Co Subway Co Amusement Park Hotels Pharmaceutical Co. Travel agency Department store etc Prefectural Government*8 Public health center*9 scene Hospitals First responders Fire Police Media Avian Flu Outbreaks In Indonesia Hospital A Hospital B Index case AB from Indonesia

11. Injecting Information University Hospital A Sep 17: A Japanese branch manager (62 years old male) in Indonesia had returned to Japan at September 11th, and signs of influenza like illness progressed. Although he had been followed as common cold by a family doctor, his condition was getting worse and he became aware of dyspnea. Then, he admitted to University Hospital A. He died at September 21st, and the diagnoses were non-specified pneumonia plus cardiac failure. Sep 23: First patient’s son (28 years old male), who stayed and cared his father at the hospital A, got similar symptoms, and visited ER of the hospital A with his sister (26 years old, female), who had sometimes cough. Because all the beds were occupied of the hospital A, he needed to stay at ER for overnight. He was treated with oxygen, inhalation and drip infusion. Index Case Son of index case

12. University Hospital A Injecting Information Family A 9/13 onset 9/21 death Pat 1 （62Y） Pat 2 （60Y） 9/21 onset 9/26 death 9/22 onset Pat 8 （7８Y） 9/23 onset 9/23 onset Pat 3 （28Y） Pat 5 （24Y） Pat 6 （27Y） Pat 4 （26Y） Patient: Contact with pat 2 at ER infant Visit Family A Wind Tower 9/26 onset 9/28 onset Pat 7 （37Y） Nurse: Contact with pat 3 & pat 4 at the hospital Ref. N Engl J Med. 2003 May 15;348(20):1995-2005.

13. University Hospital B Injecting Information 9/17 onset 9/21 death Staying at the same Floor of the same hotel Pat 1 Male 35Y death Wife 9/21 onset Contact at waiting room of hospital B Pat 2 Female 32Y Pat 3 Female 32Y Nurse Pat 4 Male 70Y 9/21 onset Care pat 2 at ICU for 6 hours Care pat 4 at bedside Pat 6 Female 38Y Nurse Same clinical ward with pat 4 Met pat 4 at hotel and hospital 9/25 onset Pat 5 Female 33Y Nurse Pat 7 Female 47Y Nurse Pat 8 Female 54Y Nurse Pat 9 Male 50Y Pat 10 Male 56Y Ref: N Engl J Med. 2003 May 15;348(20):1977-85.

14. Singapore A Japanese tourist Exposure Narita International Airport Hotel All over Japan Exposure An Indonesian tourist Hospitals Exposure Tokyo Disney Land Exposure Mikura island Clinic where far from main island do not have airport but heliport. ship is available but takes long time to reach,

15. Wind Tower High school 愛 愛 Wind tower Hosp A Junior High school University Hospital A Elementary school

16. Injecting Information Tokyo prefecture Sep 20: Phone call from a doctor of Mikura island: 6 family members have got serious pneumonia who came back from Tokyo Disney Land. 7 neighbors started fever and cough, still not serious yet. Carrying these patients by ship is danger and would you consider sending a helicopter? Sep 24: Phone call from health consulting office at Wind Tower with 42 stories: 5 residents are state of respiratory distress. All hospitals nearby rejected due to no beds available. Would you seek hospital beds for us? Sep 25: Phone call from health consulting office at Wind Tower: We’ve got a problem. Many of residents are complaining high fever and dyspnea. They have little connection within the Tower, thus infectious agents were disseminated through air. We have approximately 700 residents in this Tower and 10% are now sick, which is more than 10 times of yesterday.

17. Tokyo prefectural government Influenza in Indonesia Pandemic? News central gov. Self-Defense Forces Local fire department Threat letter against fish food shop Media Office of Emergency Management Overt terro Helicopter Pneumonia outbreak at Mikura Island From Tokyo Pref. Local public health Wind Tower quarantine Anthrax case in Hosp C: News Chiba Pref Anthrax? Hospital B: Need more staff Central Gov. Outbreaks in Hosp A, B and Wind Tower: News Fire department Suspect Avian Flu Department store Ministry of Health Media Mikura Dispatch staff Dispatch medical staff with helicopters of self defense forces to Mikura: Consider quarantine whole island central gov. Central Gov. Media Governor appealed Self-imposed control Japan Rail

18. Quarantine Wind Tower High school 愛 愛 Local government Hospital Quarantine as a whole island Tower

19. Injecting Information District General Hospital C Sep 17: 72 years old male transferred to ER of District General Hospital C by ambulance for fever, chest pain in swallowing and dyspnea. The diagnosis was mediastainal abscess, of which chest x-ray findings are similar to those of inhalation anthrax. Players of hospital C did not showed any reactions to this case. FALSE Sep 19: 56 years old fisherman visited for District General Hospital C for fever, cough and dyspnea. Players of hospital C did not showed any reactions to this case, too. TRUE Sep 22: Phone call from laboratory: Gram positive rods were detected in spinal fluid and blood of second patient, suspecting Bacillus Anthracis. Although the appearance of the organism was certainly consistent with another bacillus species, such as B. cereus or B. subtilis, these pathogens would not have been expected to be found in an otherwise healthy man. Thus, the case of fisherman was suspected inhalation anthrax and hospital C informed it to a local public health center. Index case’s wife and five other patients who were in the fish market at 9 11th visited the hospital for respiratory symptoms.

20. Injecting Information Ciprofloxacin <0.06* Rifampin 0.5* Tetracycline 0.06* Vancomycin 1-2* Penicillin <0.06** Clindamycin <0.5*Chloro 4* District General Hospital C Sep 23: Results from drug sensitivity analysis phone and fax by laboratory. Cipro and penicillin were sensitive. Sep 25. 25 years old male visited the hospital for abdominal pain and distension. 10 days ago, he ate fish meat bought at a fish shop, but never been to fish market. After operation, he recovered. His diagnosis was confirmed as intestinal anthrax. This episode suggest that fish meat traded at the fish market September 11th is a risk for intestinal anthrax. All the fish meat should be traced and if it is too late, someone has to decide whether antibiotics are distributed to the people at risk as a post exposure prophylaxis and what extent.

21. Scenario of Anthrax attack Expected: Observed: Law enforcement side Public health side Local police office Hospital C Local public health center accept Prefectural Police: NBC unit Prefectural government pharmaceutical company offer Ministry of health National police agency central gov. Media

22. Chiba prefectural government central gov. Local public health Local public health Influenza in Indonesia Pandemic? News Recognized SARS Travel agency DMAT Ministry of Health Local police office central gov. Threat letter against fish food shop Fire d Self-Defense Forces Tokyo Media Local police office Dispatch NBC unit Decontamination Pneumonia outbreak at Mikura Island From Tokyo Pref. Local public health Ministry of Health Hotel A secret base of terrorist: News Hospital B: Need more staff Hospital B Anthrax case in Hosp C: News Local public health Fire department Recognized Anthrax Stadium: white powder Disney Land Media Ministry of Health Office of Emergency Management Local police office Dispatch NBC unit Mayor of city Hospital B Media Media Recognized outbreak of unknown origin: Suspect Avian Influenza

23. Overt Terrorism Terrorist group: earth underground; “TUSK on the Earth” declared bioterrorism using SARS virus and anthrax, which included information known only by criminals. Press Conference central gov. Ministry of Health Ministry of Foreign Affaires Ministry of internal affairs and communications Media Journalist Live broadcasting

24. Process Information Degradation of Information: SARS case CDC WHO: Japanese Embassy in foreign countries overseas Central Gov Nosocomical Infection Maybe…. Foreign Affaires*2 M. Health*1 Police*4 Outbreak of respiratory disease caused by unknown origin Central Defense*3 Transport*7 Infectious disease*10 Business Airport Aviation Railroad Co Subway Co Amusement Park Hotels Pharmaceutical Co. Travel agency Department store etc Prefectural Government*8 Hospitals are critical. Public health center*9 We’ve got a problem. scene Hospitals First responders Fire Police Media Epidemic of SARS

25. Process Information Degradation of Information: Anthrax case CDC WHO: Japanese Embassy in foreign countries overseas Perhaps, some patients are suspected anthrax. Central Gov Foreign Affaires*2 M. Health*1 Police*4 Central There are patients with anthrax. Defense*3 Transport*7 Infectious disease*10 Business Airport Aviation Railroad Co Subway Co Amusement Park Hotels Pharmaceutical Co. Travel agency Department store etc Prefectural Government*8 There are many patients with anthrax. Public health center*9 We have many patients with anthrax. They can be exposed to anthrax spore at fish market. scene Hospitals First responders Fire Police Media Epidemic of Anthrax

26. Process Information • Doctors tended to • concentrate their attention on diagnosis and treatment of patients: do not know what’s going on in surrounding area and nation; • do all operations by themselves: do not ask for help; • do not have press conference.

27. Mass patients transfer Hospital WHICH? Island Prefectural government Tower

28. Lessons from the Exercise Process information: Media: Panic: Crises at hospitals: Mass patients transfer: Therapeutic priorities: Post exposure prophylaxis: Leadership: