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October 28, 201310:00 AM – 2:00 PM

Napa County 2013 Medical Health Tabletop Exercise

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The 2013 Statewide Medical and Health Exercise is sponsored by:

• California Emergency Medical Services Authority • California Department of Public Health

In collaboration with:• California Hospital Association • California Association of Health Facilities • California Primary Care Association • California Emergency Management • Response partners representing local health

departments, emergency medical services, public safety and healthcare facilities

Welcome and Introductions

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Welcome and Introductions

Introduction of Exercise Planners and Facilitators

Housekeeping Issues

Agenda Review

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To evaluate current response concepts, plans, and capabilities related to a medical surge of patients from a foodborne illness outbreak in the local community.

The exercise will focus on the coordination of surveillance activities and health system capabilities anticipated when managing a medical surge among community healthcare partners.

Exercise Purpose

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Exercise Target Capabilities

Public Health Epidemiology & Surveillance

Emergency Public Information & Communications

Emergency Operations Center Management & Medical Surge

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Evaluate ability to:

Activate surge plans

Implement the Incident Command System

Request, distribute, track and return resources in accordance with the California Public Health Emergency Operations Manual (EOM)

Coordinate risk communication

Tabletop Exercise Objectives

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Evaluate ability to:

Issue public information notifications

Conduct surveillance and epidemiological investigations

Implement necessary control measures to stop further cases of illness or disease

Tabletop Exercise Objectives

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Scenario:

Napa residents are presenting to healthcare providers with abdominal pain and bloody diarrhea in above average numbers

Some patients are needing hospital and ICU admission

A foodborne disease is suspected

Tabletop Exercise Scenario

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• Dr. Jennifer Henn, Epidemiologist• Napa County Public Health

• Dr. Karen Smith, Health Officer• Napa County Public Health

• Jahniah McGill, Registered Environmental Health Specialist• Environmental Health, Napa County

Subject Matter Experts

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EPIDEMIOLOGY

EpidemiologistNapa County Public Health

Dr. Jennifer Henn

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EPIDEMIOLOGY OF A FOODBORNE ILLNESS

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FOODBORNE ILLNESSES

• Caused by ingestion of contaminated food

• Can also be spread via other modes

• Gastrointestinal tract symptomsNausea & vomitingDiarrheaAbdominal pain

• Nonspecific symptoms outside the G.I. tract

• Children under 5, older adults and medically fragile are most vulnerable 12

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FOODBORNE ILLNESSES

An estimated 1 in 6 suffer from foodborne illnesses annually leading to an estimated:

48 million cases 128,000 hospitalizations 3,000 deaths $35 billion in medical costs & lost productivity

>1,000 outbreaks detected annually

(Painter JA, Hoekstra RM, Ayers T, Tauxe RV, Braden CR, Angulo FJ, et al. Attribution of foodborne illnesses, hospitalizations, and deaths to food commodities by using outbreak data, United States, 1998–2008. Emerg Infect Dis [Internet]. 2013.) 13

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DAILY DOUBLE

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What foodborne disease do these foods have in common?

• Raw sprouts• Pizza• Cookie dough• Fresh spinach• Ground beef patties• Romaine lettuce

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SHIGA TOXIN PRODUCING E. COLI

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E. COLI O157:H7

First recognized as pathogen in 1982

First outbreak traced to hamburgers

USDA banned sale of raw meat containing E. coli O157:H7 in 1994

Many outbreaks now linked to contaminated raw vegetables (e.g., sprouts, leafy greens) and other contaminated ready to eat foods

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STEC OUTBREAKS

2012Multistate Outbreak of Shiga Toxin-producing Escherichia coli O157:H7 Infections Linked to

Organic Spinach and Spring Mix Blend

Multistate Outbreak of Shiga Toxin-producing Escherichia coli O145 Infections

Source not identified

Multistate Outbreak of Shiga toxin-producing Escherichia coli O26 Infections Linked to Raw Clover Sprouts at Jimmy John's Restaurants

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STEC OUTBREAKS

2011

Multistate Outbreak of E. coli O157:H7 Infections Linked to Romaine Lettuce

Outbreak of Shiga toxin-producing E. coli O104 (STEC O104:H4) Infections Associated with Travel

to Germany (and consumption of raw sprouts) Multistate Outbreak of E. coli O157:H7 Infections

Associated with Lebanon Bologna

Multistate Outbreak of E. coli O157:H7 Infections Associated with In-shell Hazelnuts

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E. COLI CONTAMINATION AN EXAMPLE

Multistate E. coli O157:H7 outbreak linked to baby spinach in 2006 (205 cases, 102 hospitalizations, 3 deaths)

Outbreak strain isolated from both cattle and feral swine feces near spinach field

Spinach from 1 field with E. coli contamination mixed with spinach and lettuce from other farms at central processing plants

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CONTAMINATION AN EXAMPLE

Feral pigs had access to both cattle and spinach fields

Surface water used for irrigation potentially contaminated with E. coli

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E. COLI AND MEDICAL SURGE

AN EXAMPLEOutbreak of E. coli O104:H4 in 2011

– 3,816 cases in Germany; 54 deaths

– 845 (22%) involved Hemolytic Uremic Syndrome (HUS)

Hospitals in most affected areas of Germany experienced large influx of patients with HUS and other complications due to E. coli infection– Doubled number of staff

– Tripled machines for dialysis and plasma exchange

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E. COLI AND MEDICAL SURGE

AN EXAMPLEVideo news clip:

http://www.bbc.co.uk/news/world-13696131

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SHIGA TOXIN PRODUCING E. COLI

Common reservoirs = cattle and other ruminants

Vehicles in past outbreaks = ground beef, petting zoos, raw vegetables and fruit, unpasteurized apple cider, water, etc.

Growth requirements = facultative anaerobe, non-sporulating bacterium

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E. COLI - EPIDEMIOLOGY

Mode of Transmission Ingestion of food contaminated by traces of feces or direct

contact with animals and their environment

Incubation Period Range from 2-10 days after exposure; median 3-4 days

Period of Communicability When the bacteria is being excreted 1 week or less (adults) or up to 3 weeks (children)

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SHIGA TOXIN PRODUCING E. COLI (STEC)

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Some E. coli bacteria produce shiga toxin When shiga toxin enters the bloodstream it

can damage the red blood cellsSeverity of illness ranges from mild diarrhea

to life threatening HUS

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CLINICAL SYMPTOMS AND TREATMENT OF

STEC INFECTIONS

Health OfficerNapa County Public Health

Dr. Karen Smith

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SYMPTOMS

Symptoms of E. coli infection: Watery and often bloody diarrhea Abdominal cramping Abdominal pain Little or no fever

Most people will recover within 5 to 10 days

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HEMOLYTIC UREMIC SYNDROME (HUS)

Life threatening condition that often requires ICU treatment

Triad of hemolytic anemia, thrombocytopenia, and acute renal failure

Often requires blood transfusions and dialysis during acute phase

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HEMOLYTIC UREMIC SYNDROME (HUS)

On average, HUS occurs in ~6% of E. coli patients

Case fatality rate of 3-5%

Most cases of HUS occur in children under 5

Use of antibiotics and anti-diarrheal medication to treat E. coli infection increases risk of HUS

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DIALYSIS

Average length of dialysis for patients with HUS due to E. coli infection is 5-7 days (but can vary widely)

Peritoneal dialysis widely used for pediatric patients

Hemodialysis also suitable for children - may be preferable in patients with severe abdominal pain

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MANAGEMENT OF HUS

Successful management of HUS includes:

• Fluid therapy

• Management of acute renal failure

- ~50% of HUS patients require dialysis

• Blood and/or plasma transfusion - Most children require packed RBC transfusion

• Management of hypertension• Nutritional support and pain management

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STEC – SPECIAL CONSIDERATIONS

Most E. coli related HUS cases seen in children < 5, but elderly and immunocompromised are also at increased risk for HUS

Elderly patients at higher risk for E. coli blood stream infection (bacteremia) and may develop additional complications due to presence of other illnesses

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FOODBORNE OUTBREAK RESPONSE

EpidemiologistNapa County Public Health

Dr. Jennifer Henn

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OUTBREAK INVESTIGATION GOALS

Identify all cases

Find a common exposure

Determine cause

Stop the exposure

Prevent future cases

Notify providers

Inform the public34

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A COORDINATED RESPONSE

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Public Health

Laboratory Environmental Health

Foodborne Illness

Response Team

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Public Health Nurses and Disease Investigators

• Interview patients• Collect clinical specimens from patients• Administer questionnaires for epidemiologic

studies• Advise patients on how to prevent spread of

illness• Provide public health education & guidance

(i.e., health advisories and health alerts)36

PUBLIC HEALTH RESPONSE ROLE

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Epidemiologists

• Analyze data from pathogen-specific surveillance and identify clusters/outbreaks

• Characterize cases by time, place, and person• Plan epidemiologic studies• Interview cases and healthy controls• Analyze and interprets results of epidemiologic

studies

PUBLIC HEALTH RESPONSE ROLE

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Public Health Laboratory staff

• Analyze clinical, food, and environmental specimens

• Interpret test results and “fingerprint” strains• Advise about tests and collection, handling,

storage, and transport of specimens• Coordinate additional testing by partner labs

PUBLIC HEALTH LABORATORY RESPONSE

ROLE

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WHO ARE THE PUBLIC HEALTH STATE AND

FEDERAL PARTNERS? • California Emerging Infections

Program (CEIP)

• California Department of Public Health (CDPH)

• Centers for Disease Control and Prevention (CDC)

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E. COLI O157 CASE CONFIRMATION PATHWAY

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ENVIRONMENTAL HEALTH RESPONSE

Registered Environmental Health Specialist

Napa County Environmental Health

Jahniah McGill, MPH

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HOW DOES ENVIRONMENTAL HEALTH BECOME AWARE OF FOOD

RELATED EVENTS?Environmental Health

• Reporting Methods− Online complaint system− Telephone complaint

• Reporters of Illness− Consumer complaints− Food facility operators− Health and Human Services: Public Health

• State & Federal Partners− California Food & Drug Branch (CDPH)− US Food and Drug Administration (FDA)− US Department of Agriculture (USDA)

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Environmental Health Inspectors focus on how the food became contaminated:

• Receive and interpret foodborne illness complaints• Investigate suspected food and/or food establishment

− Interview food workers and managers− Examine food storage, handling, preparation, and

service − Identify risk factors that resulted in food contamination− Collect environmental and food samples− Collect paperwork

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ENVIRONMENTAL HEALTH RESPONSE ROLE

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ENVIRONMENTAL HEALTH RESPONSE ROLE

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Environmental Health Inspectors focus on how the food became contaminated:

Implement control measures• Employee education• Disposal of contaminated food• Impound• Closure of premises• Administrative hearing process• Probationary period

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ENVIRONMENTAL HEALTH RESPONSE ROLE

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Environmental Health Inspectors refer to the following agencies:• CDPH Food and Drug Branch (CDPH)

− Manufacturers, Processors, Wholesale− Seafood and Shellfish− Recall of Foods

• CA Department of Food and Agriculture (CDFA)− All Meat and Dairy Products

• U.S. Food and Drug Administration (FDA)− Interstate Manufactures, Processors, Wholesale

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HOW DO YOU CONTACT ENVIRONMENTAL

HEALTH?

PBES: Environmental Health Division

Main Phone: (707) 253-4471 or (707) 253-4417

Main E-mail: Environmental@countyofnapa.org

County Website:

http://www.countyofnapa.org/PBES/Environmental/

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Do not fight the scenario

Assume the scenario is real and may impact the jurisdiction and the participants

Participate in a collegial manner: share policies, plans and practices that may benefit others

Exercise Ground Rules

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Be respectful: allow others to speak and finish their statements

Follow communications etiquette: turn off cell phones, computers, and any other electronic data equipment

Exercise Ground Rules

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The exercise consists of three modules plus an addendum for planning the November 21, 2013 Functional Exercise

Each module will identify the key issues followed by questions for discussion

Participants are encouraged to share their plans, policies, strengths and gaps as identified in the Organizational Self Assessments

Tabletop Exercise

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On November 18, 2013, healthcare providers at community health centers, private physician’s offices and local emergency departments began seeing previously healthy patients with complaints of abdominal pain throughout Napa County.

Scenario

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Within one day, 40 cases of bloody diarrhea had been reported by 10 healthcare providers at community health centers, private physician’s offices and local emergency departments in the county.

Two days after the first reports of abdominal pain and bloody diarrhea, 4 patients (of which, 2 are pediatric) were admitted to the Intensive Care Unit with symptoms of decreased urine output, lethargy and persistent bloody diarrhea. These patients were diagnosed with hemolytic uremic syndrome. Cases presenting similar symptoms continue to be reported throughout the county.

Scenario (Continued)

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Five days after the first reported case, 225 patients (approximately 10% with HUS) have been identified with similar presenting symptoms at local hospitals, community health centers and private physician practices.

Scenario (Continued)

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Healthcare facility staff has requested guidance from the local Public Health Laboratory on appropriate protocols for specimen collection and laboratory techniques to confirm the diagnosis.

Healthcare facilities are requesting guidance on necessary levels of isolation and personal protective equipment requirements for staff.

Scenario (Continued)

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Key Issues:

Surveillance and epidemiological investigation coordinated with the healthcare partners

Implement control measures

Module 1: Public Health Surveillance and Epidemiological Investigation

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1. When and how would your organization/agency be made aware of an increase in Shiga Toxin-producing E. coli isolates within your jurisdiction? a. Are there multiple modes of communication for this

kind of information?

2. What would prompt an investigation, and who would undertake the investigation and analysis if an outbreak were to occur in your jurisdiction?

Questions for Discussion

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3. How does your organization/agency collaborate with the laboratories?a. How is testing prioritized?

4. How are control measures issued by Public Health, Environmental Health, healthcare facilities? a. How are the control measures implemented by

each?

Questions for Discussion

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LUNCH

BREAK

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Key Issues:

Alerting and notification of personnel

Internal and external communications

Risk communication messaging

Module 2: Emergency Public Information and Communications

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1. What mechanisms and/or technologies are in place to alert and notify your staff of activation of your facility’s emergency operations plan?

a. How do you notify staff of activation?

b. Who is responsible to do that?

c. How often do you test this system?

d. Has this system been used in a real event?

e. Who else do you notify of activation?

f. How does that occur?

Questions for Discussion

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2. How do you share information with Public Health?

a. What information do you share?

b. What information do you expect from Public Health?

c. How do you communicate your facility status (and bed

availability) to the local medical health system?

d. How does this information get to the state?

Questions for Discussion

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3. What is your risk communication plan to notify staff, patients, clients and/or stakeholders of a foodborne illness outbreak?

a. Who approves the information to be shared?

b. What communication methods are used?

c. How does your organization participate in a Joint

Information System (JIS)?

d. What would warrant opening a Joint Information

Center (JIC)?

e. How do you manage inquiries from the media,

stakeholders, and the general public?

Questions for Discussion

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Ambulance companies are reporting an increase in call volume and extended delays in offloading patients at local emergency departments. Hospitals are experiencing continuing surge with increasing emergency department wait times.

The initial epidemiologic investigation has not revealed a consistent pattern of age, race, occupation, geographic distribution or previous symptomatology among patients which might indicate a source of the offending agent.

Scenario (Continued)

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Key Issues:

Response is coordinated through the use of Incident Command System principles and Command Centers/Emergency Operations Centers

Incident Action Plans are developed to guide and document the response and recovery phases

Activation of Surge Plans

Request and/or response to resource requests

Module 3: Emergency Operations Center Management and Medical Surge

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1. How do you plan for an influx of patients including the access and functional needs population?

a. What types of services can be altered, postponed or relocated to other sites?

b. Have clinical providers been active in the decision making for alteration of services?

Questions for Discussion

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2. Which partner organizations can assist in providing services that you must alter or suspend due to a medical surge?

a. Do you have Memoranda of Understanding signed with these partner organizations?

3. How do you request, respond to, distribute, track and/or return resources in accordance with the California Public Health and Medical Emergency Operations Manual?

Questions for Discussion

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Napa County Public Health Officer

Dr. Karen Smith

Resource Requesting

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Medical & Public Health Resources

• Personnel• Services• Supplies and Equipment• Transportation• Facilities

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Healthcare Facility Managers

How to Obtain Resources:• Communication through accepted local

protocols• Communicating resource arrangements

minimized duplication of efforts

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HC Facility Resource Utilization

• Determine if current resources will meet the anticipated needs

• Prioritize/conserve what’s available

• Contact suppliers/contractors

• Implement existing agreements

• Request help from the HHSA/DOC - MHOAC

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HHSA Department Operations Center (DOC)

DOC Director

Operations Section

Medical Branch

Health Branch

Planning

SectionLogistics Section

Finance Section

PIO Safety Officer

Liaison Officer

Health Officer

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DOC Medical & Health Branch

Operations Section

Medical Branch

EMS/TransportPatient

Tracking

Healthcare Facilities

Coordination

Alternate Care Site

Health Branch

Communicable Disease

Laboratory

Mass Prophylaxis

Activate branches as

needed

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CA Mutual Aid System

• CA disaster & Civil Defense Master Mutual Aid Agreement (MAA)

• Discipline-Specific Mutual Aid Agreements• Health Care Facilities Mutual Aid or Mutual

Assistance Agreements

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CA Mutual Aid Regions

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1

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Regional Disaster Medical & Health Coordinator/Specialist (RDMC/S)

REOCMedical Health Branch

RDMHC/S Program

OA EOCMed. Health Branch

MHOAC Program

OA EOCMed. Health Branch

MHOAC Program

OA EOCMed. Health Branch

MHOAC Program

Affected Local Jurisdictions

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Who You Gonna Call?

Public Health/ HHSA!!!

Public Health/HHSA DOC is your gateway to CA’s mutual aid…

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You Survived!

Tabletop Conclusion

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HOT WASH

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The scenario will be a medical surge due to foodborne illness.

Customization of the exercise allows incorporating other objectives as needed.

Examples include issues identified in past exercises, new training or equipment, or new policies and procedures.

Planning for the November Functional Exercise

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Exercise Level of Play:

What level of exercise play do the organizations/agencies represented today anticipate for the November 21, 2013 exercise?

Examples include communications drill, functional and full scale exercises, level of play may include use of simulated patients, movement of patients to healthcare facilities, activation of the joint information center, provision of mutual aid, etc.

Will your organization/agency activate its Command Center/Emergency Operations Center?

November ExerciseIssues for Consideration

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On November 21, 2013, the California Department of Public Health and the California Emergency Medical Services Authority will open the Medical and Health Coordination Center (Formerly the Joint Emergency Operations Center).

The California Emergency Management Agency is anticipated to participate by opening the State Operations Center and the Regional Emergency Operations Centers to support local and regional exercise play.

This will provide the opportunity for local participants to request additional resources, submit and receive situation status reports and respond to California Health Alert Network (or other notification systems) messages and receive further direction.

Role of State Agencies

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Evaluations

Please

complete

your

Evaluation…

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Thank You

For Your Participation

Additional materials may be found on:

California Statewide Medical and HealthTraining and Exercise Program website:

www.californiamedicalhealthexercise.com