Tabletop Exercise

1
Tabletop Exercise

• BT Epidemiologic Response Team Training
• September 25, 2003

2
Goals

• BPH and BT epi response team members will
  understand
• 1. The notification-call down procedure during
• a BT event
• 2. Who is in charge as a BT event escalates. 
• Team roles in outbreak management and
• contact tracing as a BT event escalates.
• 4. Disease control, exposure assessment, and
  
• contact surveillance procedures

3
Day 1 Sept. 25, ThursdayThe Unknown Powder
4
6 pm The State Police (SP) raid a meth lab in
Harrison County and find 25 pounds of a powdered
material. A person (Billie Bob) is arrested at
the lab and is complaining of fever, cough, and
has severe difficulty breathing. Billie Bob is a
known drug dealer in Harrison County and is also
affiliated with a local Harrison County white
supremacy group. The local white supremacy group
is part of a national organization that is under
surveillance by the FBI and SP. The FBI learned
several months before that the national
organization had announced to its local groups
that democrat politicians and candidates for
president and congress who oppose the current
Bush administrations anti-terrorist program are
traitors and should be removed from office by any
means necessary. Billie Bob passed out while
being taken to jail, was taken to the Harrison
County Hospital ER and was admitted to the
hospital with severe respiratory distress. The
ER suspected pneumonia.
5
 700 pm SP calls Harrison County Health
Department (HCHD) to get the powder tested. SP
explains the ties between the local terrorist
group and the national organization and the
threat to the democratic party candidates and
campaign workers. The FBI and SP assumed the
powder was cocaine or another drug but wanted to
rule out any biological agents. Hazmat team puts
sample of powder in a bag and waits for SP to
transport sample to state lab (OLS). SP secures
the crime scene and notifies the FBI, which sends
an investigation team. SP notifies Harrison
County Sheriff who notifies local OES director.
 HCHD calls Bob White. Bob calls IDEP and asks
about forms needed to send samples to OLS. SP
transports powder to OLS. 
6
900 pm Radio, TV and newspaper reporters begin
to call local HD and the IDEP on-call number
Ram Nambiar is the IDEP on-call duty
officer. HCHD tells press that a meth lab was
raided, an unknown powder was confiscated which
was suspected to be drugs, and a sample of powder
was sent to OLS for testing.
7
Has a possible BT event occurred? What is the
notification procedure? Who does Ram Nambiar,
the IDEP on-call duty officer call? Who should
be notified within BPH and outside BPH? Who is
in charge of this incident? What is Rams
responsibility? What is the IDEP/BT epi team
role at this time?  What information does IDEP
want to know at this time?  What does IDEP
recommend/assure is happening at this
time? What does Ram tell the reporter who calls
the IDEP emergency number?
8
Day 2 Sept. 26, FridayPowder is Y. pestis
9
2 pm Billie Bob goes into respiratory distress
and dies. Hospital notifies HD. Cause of death
is pneumonia unknown cause. Blood and sputum
samples sent to hospital lab for analysis.9.pm
OLS determines that the sample of powder from
the meth lab is Y. pestis ground to a 1-5 um
particle size. OLS notifies Dr. Cathy Slemp,
IDEP, SP, FBI, and HCHD. Raja is the IDEP
on-call duty officer and notifies Dr. Bixler who
calls Loretta Haddy (State Epidemiologist).
Harrison County Hospital sends Billie Bobs
specimens to OLS.  The HCHD Health Officer (HO)
calls IDEP and tells Raja that he is notifying
all HCPs and ERs to watch for plague cases and is
sending an alert to Radio and TV stations
announcing the incident. HCHD wants to know if
BPH is going to send out an alert.
10
930 pm HCHD notifies its local OES director
who notifies WVOES. 1030 WVOES convenes
a conference call with BPH, SP, FBI, HCHD, and
Harrison County OES Director. 1130 pm The
WVEOC is activated. Governor appoints a task
force. Governor makes an announcement to the
media.
11
Has a possible BT event occurred? Who sits in on
the WVOES conference call? Who is in charge at
BPH? Who is on the response team at BPH? What
is the IDEP/BT epi team role at this
time? What is the BPH response now?
12
Day 3 September 27, SaturdayThe Outbreak
13
8 am BPH advises LHDs to notify all their ERs
and HCPs to report all cases with clinical signs
and symptoms consistent with a working case
definition. BPH advises all LHDs to notify IDEP
of any cases via the IDEP emergency call
number.  What is the working case definition
at this time?
14
6 am-12 noon ERs at Huntington Hospital, CAMC,
Ruby Memorial, and Wheeling Hospital report 40
cases of fever, cough, and signs of pneumonia to
their LHDs. All cases present with signs of
bloody sputum, malaise, nausea, vomiting, and
abdominal pain. One-two cases at each ER
additionally presented with painful swollen lymph
nodes. Plague is suspected at ERs. CAMC 10
Huntington 10 Ruby 12 Wheeling 8
15
12-1 pm HOs in Cabell-Huntington, K/C,
Monongalia, and Wheeling-Ohio County HDs meet
with their nurses and sanitarians to decide on
strategy.  -  HDs report cases to IDEP on-call
duty officer as they are reported to the
HDs. -   HOs and head nurses prepare alerts for
media. HOs call BPH and ask if BPH is
putting out an alert.  -   Nurses call all
ERs, primary care providers, and urgent care
clinics, and notify by FAX all HCPs to notify
HD of any new cases meeting the case
definition. - HOs and nurses visit hospitals
to investigate cases.
16
Are symptoms consistent with plague? Is this an
outbreak of plague? Does BPH and LHDs put out
an alert before cases are confirmed by OLS? How
is alert coordinated with HDs? Who is in charge
at BPH? Who is on the outbreak management team?
What are state, local, and regional
epidemiologist roles and responsibilities? Does
BPH send epi teams to counties to assist in the
investigation? Who goes into the field and who
stays at outbreak management headquarters?
17
How do field personnel communicate with field
teams?  Do we tell LHD nurse teams to wait
before proceeding to interview cases until
BPH/IDEP teams arrive? What instructions does
BPH/IDEP have for LHD nurse teams who will be
interviewing cases? (e.g., line lists of cases,
disease prevention and control objectives, line
list of contacts, antibiotics for plague
treatment and post-exposure prophylaxis, the epi
investigation protocol to be followed such as
hypotheses to be addressed, study design, number
and type of cases and/or noncases to be
interviewed, questions to be asked, forms to be
used for data gathering etc)How is contact
tracing and surveillance coordinated? What are
the state, local, and regional epidemiologist
responsibilities at this time?
18
100 pm BPH establishes an incident command
center in DSDC conference room with an emergency
call-in number for HDs. All HDs are notified of
the call-in number. BPH sends plague protocol to
all HDs. Hospitals ask local HDs where to send
specimens for testing. HDs call BPH command
center for consultation.   What specimens
should be collected for testing? What labs do
testing for Y. pestis? Who is ensuring that
clinical specimen are taken and submitted to the
lab on all suspected cases? Who will track the
lab results?
19
2 pm CDC announces that similar outbreaks of
flu-like symptoms consistent with plague are
occurring in 20 other states. A total of 1000
cases have been reported in the US from 5 am
through 3 pm. State and local health departments
are on their own. CDC is concentrating on the
larger metropolitan areas.  CDC develops a
working case definition and notifies states. BPH
notifies HDs of the new working case definition
fever and cough or who had direct contact with a
probable or confirmed plague case since September
19-25.
20
210 pm HDs assume a plague outbreak and
determine that local hospitals and pharmacies
have enough doses of streptomycin, gentamycin,
doxycycline, and ciprofloxacin for treatment of
cases and post exposure prophylaxis of
contacts.Hospitals send clinical specimens to
OLS. Do hospitals begin treatment of cases and
LHDs begin prophylaxis of household contacts
prior to lab confirmation? IDEP advises HDs to
collect information on cases travel and activity
schedules during previous 7 days using the IDEP
forms 3B-C in order to identify common exposures.
HDs are also advised to identify all contacts
according to the protocol using forms 2A-E.
21
All 40 cases reported in the 4 hospitals
satisfied the case definition. Forms 3A-C were
completed on all 40 cases and sent to IDEP and
IDEP found the following common activities -
2 cases had ties with the terrorist cell  - 1
case had no known ties with the terrorist cell or
democratic rallies or county headquarters.
22
- 28 of the 40 cases had attended a democratic
campaign rally in their county 4 days ago
(Sept. 23) Charleston (8), Wheeling (4),
Huntington (8), and Morgantown (8)  - 30 of
the 40 cases had attended a statewide democratic
rally in Charleston 3 days ago (Sept.
24). - 37 of the 40 cases had worked in
democratic field headquarters in these counties
within last 7 days (Sept 20-27). - 37 of the
40 cases had attended either a local rally or the
state rally or both.- 10 had attended a
Marshall football game in Huntington and 10
had attended a WVU football game in Morgantown on
Sept. 20.
23
BPH/IDEP provides this information to incident
command at the WVEOC (SP, FBI, WOES) and local
HDs. WVOES notifies local OES directors and
local police. 230 pm Incident command
centers are set up at each county with SP,
Sheriff, fire, local OES, and public health
represented. 3 pm FBI and local law
enforcement task force interrogate the 2 cases
with known ties to the Harrison County white
supremacy group and the two cases admitted that
they participated in exposing democratic campaign
workers to Y. pestis. They would not disclose
where the exposure took place. Incident command
centers turn to public health for further
investigations.
24
Law enforcement task force reports that
approximately 2,400 people attended local
democratic rallies in 8 counties 4 days ago
(about 300 in each county) and about 5,000 people
attended the state rally in Charleston 3 days
ago. Head counts were available from the state
democratic committee rally organizers but no list
of names were available.
25
What type of antibiotics do we need? How many
people possibly need antibiotics? How long do we
have to provide treatment of cases and
post-exposure prophylaxis of exposed and
contacts? Who will check for availability of
antibiotics in state? Is the SNS activated yet?
Are there enough doses of antibiotics available
in the regions around the hospitals for treatment
of cases and post-exposure prophylaxis of exposed
people and case-contacts? How do we assess
source of exposure more specifically? (e.g.,
hypotheses, study design, who should be
interviewed, questions to be asked, forms to be
used, who will collect and evaluate the data, how
are the investigations to be managed, what are
the state and local roles and responsibilities). 
Should environmental samples be taken, and if so
where and who collects them?
26
10 pm OLS identifies Y. pestis in clinical
specimens from Billie Bob. This is first
indication of Y. pestis in a patient.   Do
we do anything differently in our investigation
now?
27
Day 4 Sept. 28, SundayMore Cases 
28
8 am-4 pm 60 new cases of fever, cough, and
pneumonia like symptoms appear at ERs 5 deaths
among the 40 cases reported yesterday. 2
pm-10 pm OLS confirms Y. pestis in clinical
specimens from 20 cases reported on day 3.
 Volunteers are recruited by LHDs to begin
case-contact identification and surveillance.
Antibiotics are requested from state.
29
The FBI and state and local law enforcement task
force reports that three plague cases all had
ties with the local Harrison County terrorist
cell. Members of the cell emptied one small
plastic bag of Y. pestis into the main hallways
of each county democratic rally in 8 counties
(those counties in which cases were reported) and
in 3 main hallways at the state rally at the
Charleston Civic Center. The local HDs
interviewed cases and identified all
case-contacts. The total number of cases and
case-contacts are as follows (each case exposed 5
personal contacts and 20 health care workers and
visitors at each ER)
30
County Cases
Contacts K/C
17 105Cabell-Huntington 25
145Monongalia 25
130Wood 8
60Jackson
5 45Beckley/Raleigh
5 45Wheeling
13 85Marshal
5 45 Total
100 660
31
What are team assignments (state and local roles)
for exposure investigation, surveillance of
exposed and case-contacts, ordering and
distributing antibiotics, and providing PEP to
exposed and case-contacts?  Do we need to
order from SNS? What is the projected number of
cases?
32
Day 5-7 Sept. 29-31Monday-WednesdayMore
Cases
33
8am-4pm OLS confirms Y pestis in remainder of
20 cases reported on day 3 and 20 cases on day 4.
3 deaths. 40 new cases appear on day 5, 20 on
day 6, and 10 on day 7. The total number of
cases and contacts for surveillance are as
followsCounty Cases
ContactsK/C 27
175Cabell-Huntington 30
170Monongalia 35
225Wood 18
130Jackson 10
70Beckley/Raleigh 10
70Wheeling 18
130Reynolds
10 70Harrison
5 45 Total
170 1085
34
Does the increasing number change state/local
teams and roles? Does local HDs need assistance
in setting up clinic for prophylaxis of
contacts?How many doses do we need? How many
more cases could there be? Does BPH need to
request the SNS?  Do we need more volunteers
than we have on state and local teams for contact
tracing and surveillance? Do we need to change
our strategy for managing contact surveillance?
Where do we get more volunteers?
35
Lessons Learned?