Pandemic H1N1 Emergency Preparedness Tabletop Exercise

1. Pandemic H1N1Emergency Preparedness Tabletop Exercise HCA Education and Research July 23, 2009

2. What is a tabletop exercise? • People come together to review and discuss a hypothetical emergency situation • Designed to allow participants to talk through plans and problems • NOT designed to measure anyone’s performance • Serves as a springboard for further planning and more comprehensive exercises

3. Exercise format • The scenario has several sections • Discussion questions follow each section • At the end of the scenario, everyone will participate in a debriefing or “hotwash”

4. Exercise roles • Facilitator • Provide instructions, tell the story, introduce the questions, guide the discussion • Participants • Immerse yourself as if the scenario were truly occurring in your jurisdiction, using resources that are available to you (Emergency Operations Plan, policies, procedures, references) • Participate in the group discussions • Evaluators • Observe the exercise to evaluate the process

5. Ground rules • Respond as if the scenario is real • Play the role of your department, agency or community throughout the exercise • Operate within current resource constraints and realities

6. Objectives By the end of this exercise, you should be able to: Describe your individual and your agency’s roles in the response Identify at least one gap in your agency’s existing Emergency Operations Plan (EOP) Contact the appropriate partnering agencies during business hours as well as after hours

7. This fall in Albany...

8. Swine Flu Reports • Trending down • Reporting/testing ended • Cases mild, not in the news • Is crisis over? • Has planning stopped?

9. Hmmm - do we remember the 1918 Pandemic came in three waves?…

10. 1918 Waves • The first wave of the 1918 flu occurred in the spring of that year. That flu was very severe by usual standards but the second wave beginning 6 months later in September was the most fatal. • During the 1918 pandemic, the deadly second wave was responsible for more than 90% of the deaths for the entire pandemic. • The third wave occurred more than a year later, during the following 1919-1920 winter/spring, and was the mildest of all.

11. Other Background • 1957 the Asian Flu, occurred between September 1957 and March 1958 • The Hong Kong Flu infiltrated the globe December 1968-January 1969, with those older than 65 most likely to die. The same virus returned in waves in 1970 and 1972 • In 1976 there was a Swine Flu threat (minor) • 1977-78 Russian Flu (children and young adults)

12. Conclusions???? How do you plan for a moving target?

13. 1. Discussion • Based on our historical knowledge of pandemic influenzas, what do you think the best balance of preparedness strategies are? • What concrete steps will you take to prepare for a possible, more severe form of pandemic influenza

14. The beginning… A 47-year-old man from Albany arrives at the emergency department (ED) at Albany Med with fever, chills, malaise, cough and shortness of breath DAY 1, 9:00 a.m.

15. Across the State • In a matter of a few days, more and more cases of severe ILI illnesses are appearing in EDs and MD’s offices

16. 2. Questions • In normal circumstances, how much education do you provide to your staff and patients regarding influenza avoidance and management? • What ongoing education have you been offering to your staff regarding surveillance for a new strain of influenza? • Would you be paying attention to this series of events?

17. The Unfolding

18. Related cases? More patients arrive at Albany Med with severe flu-like illness • Three of the new patients work with the index patient and live in the surrounding area • Many went to a school banquet he attended with his wife DAY 2, 2:00 p.m.

19. You hear about it and read up on current status of virus • Antiviral resistance has emerged - inhaled zanamivir remains an option • Shanghai mutation renders virus more fit for human replication & transmission - E627K mutation in the PB2 gene, which renders the virus more fit to replicate at 33°C, the temperature of the human nose during winter months. • Previous infection with swine flu appears to offer some immunity DAY 2, 3:30 p.m.

20. Confirmation of H1N1 influenza • State reference lab reports to public health that sample is positive for Pandemic H1N1 • Specimen sent to CDC for confirmatory testing DAY 3, 12:00 p.m.

21. CDC communication Albany County confers with NYSDOH, which updates CDC • 4:30 p.m. • 6:00 p.m.A conference call is arranged; public health determines risk factors and revises hospital screening questionnaire to gather data • 6:30 p.m. CDC sends out the questionnaire via alerts on the Health Alert Network (HAN) and Epi-X No recommendations yet on PPE DAY 3

22. 3. Questions Without guidance, what infection control measures need to be taken? By whom? What sources of PPE do you have contracts with? Do you have any record of staff or patients that were affected by the Spring 2009 illness? Is this information of any value?

23. Detection…

24. Epidemiology investigation NYSDOH receives confirmation of positive H5N1 influenza from CDC • 10:30 a.m. A request for SNS materiel is relayed to CDC • 1:00 p.m.Epidemiologic contact tracing begins to identify banquet attendees and neighborhood contacts • 3:30 p.m. At the request of NYSDOH, CDC details Epidemic Intelligence Service (EIS) officers to New York to help with case investigations DAY 4

25. The illness spreads • People who also attended the awards banquet begin to seek hospital care • In addition to the index case, two more patients with suspected pandemic flu have died DAY 5, 10:00 a.m.

26. Albany Med Albany Med admits several more patients with suspected avian influenza, including two of their own healthcare workers Other hospitals in New York are seeing patients with similar symptoms DAY 5, 1:00 p.m.

27. Case count • Statewide: eight confirmed and many more suspect cases of flu • Nationwide: 120 confirmed and hundreds more suspect cases DAY 6, 3:00 p.m.

28. Severe Influenza • Worldwide • Sporadic cases of severe influenza are reported in East Asia, Eastern Europe and, most recently, in Africa • Mortality of patients exceeds 50% DAY 6, 3:00 p.m.

29. Hospitals forced to ration resources • Overwhelmed hospitals triage patients as they arrive, admitting only the most ill Albany-area hospitals report shortage of ventilators, ED beds and ICU beds DAY 5, 4:00 p.m.

30. SURGE DISCHARGE • Hospitals begin discharging patients to make room for influx • NY activates its ventilator allocation plan

31. 4. Questions • What procedures do you have in place to track swine flu within your patient population? • Describe your agency’s surge plan and your role in it. • Do you know what is in the ventilator plan? How might the allocation plan affect home care patients?

32. Questions - Communication • At times of crisis, it’s important for messages to be consistent and credible. What messages would you be giving to your staff, your patients, emergency managers, local health department and the community at this time? • Who would be giving those messages?

33. Crisis…

34. Absenteeism Crisis • Local healthcare facilities report increase in employees calling in sick; many simply unwilling to risk coming to work • Absenteeism is on the rise in essential services such as refuse collection, utilities repair and public safety • Many businesses encourage workers to telecommute or work flexible hours DAY 8

35. 5. Questions Discuss your occupational health plans for an infectious disease event If schools and day care close, what plans has your agency made for child (and elder?) care (or you if your agency has none)

36. ALLOCATION • As public health officials struggle to determine most effective control measures, you are faced with a number of crises: • You have multiple agencies that you contract with for aides. • What agreements are in place for aide allocation during an emergency? • Do you have an agreement regarding pandemic specific infection control training for aides? • The appropriate antivirals are available in limited quantities. You receive enough for 50% of your staff for seven days. • How do you allocate them when almost all direct care staff is the same high priority according to the guidance you’re given? • What is the most important goal of antiviral use at this time? DAY 6, 4:30 p.m.

37. Vaccine Arrives

38. Update • CDC further classifies outbreak as a second wave of the novel strain of swine influenza H1N1 with genetic components of avian, swine and human influenza • Person-to-person transmission • Almost 1,000 suspected cases statewide • 75 have died, including numerous healthcare workers and first responders DAY 14

39. CDC Recommends Vaccinations • Local Health Departments are asked to hold flu clinics and go into homes to vaccinate the home bound and vulnerable populations

40. If you are a LHD…describe your outreach/collaboration/planning efforts for assistance from home care If you are a home care provider, depending on your type and affiliations, describe: Efforts made to reach out to you Efforts you have made to plan collaboratively Additional ways you could assist in these efforts Resources that might assist you in your efforts Barriers

41. Alternate Care Site • Your agency is asked to assist in jointly managing and staffing an alternate care site. You are told to review joint command and assign job action sheets to agency staff who will be working at the ACS. • How will you do this? What resources will you use? Will your staff be able to function in this environment?

42. End of Pandemic Flu Scenario

43. “Hot Wash” • Where is your knowledge lacking? • What (realistic) resources do you need to improve your response capability? • Based on your knowledge of your agency’s plan, what gaps still exist in response to this type of situation? • What is the most significant lesson learned from this exercise?

44. Contact Information Alexis Silver Home Care Association of NYS (518) 810-0658 asilver@hcanys.org www.homecareprepare.org