Maryland 2008 Statewide Pandemic Influenza Exercise and CRA Albert Romanosky MD, PhD Office of Preparedness and Response Maryland Department of Health and Mental Hygiene

2CDC PHIN Conference 2008 Presentation Objectives Give a brief Overview of the Maryland 2008 Statewide Pan Flu Exercise Give a brief Overview of the Maryland 2008 Statewide Pan Flu Exercise Review the Role of Countermeasures Response Administration (CRA) in the Exercise Review the Role of Countermeasures Response Administration (CRA) in the Exercise Identify the CRA Sustainable/Key Strengths and Needs Improvement Activities Identify the CRA Sustainable/Key Strengths and Needs Improvement Activities

3CDC PHIN Conference Pan Flu Exercise Overview Modified Functional Exercise: Modified Functional Exercise: Full Scale Components Full Scale Components Three Days ( June 17-19, 2008) Three Days ( June 17-19, 2008) Compressed Pandemic Wave Weeks 6-12 and Recovery Compressed Pandemic Wave Weeks 6-12 and Recovery Designed to Address: Designed to Address: Corrective actions following previous exercises Corrective actions following previous exercises Office of Preparedness & Response identified statewide pan flu priorities and operational activities Office of Preparedness & Response identified statewide pan flu priorities and operational activities Federal Pan Flu Priorities Federal Pan Flu Priorities

4CDC PHIN Conference 2008 Overarching Exercise Goal The overall goal of the exercise was to test the expertise and capability of several components of the healthcare system to adequately identify and respond to unusual work and patient loads during a pandemic influenza outbreak.

5CDC PHIN Conference 2008 Specific Exercise Testing Requirements and Guidelines Homeland Security Exercise and Evaluation Program (HSEEP) Homeland Security Exercise and Evaluation Program (HSEEP) Assistant Secretary for Preparedness and Response (ASPR) Hospital Preparedness Program (HPP) Exercise Standards and Requirements Assistant Secretary for Preparedness and Response (ASPR) Hospital Preparedness Program (HPP) Exercise Standards and Requirements CDC Public Health Emergency Preparedness Cooperative Agreement Guidance and CDC Pan Flu Appendix 12: Overarching Exercise Objectives by Priority Area: Pandemic Flu Exercise Guidelines for Medical Surge CDC Public Health Emergency Preparedness Cooperative Agreement Guidance and CDC Pan Flu Appendix 12: Overarching Exercise Objectives by Priority Area: Pandemic Flu Exercise Guidelines for Medical Surge

6CDC PHIN Conference 2008 ASPR Hospital Preparedness Program (HPP) Exercise Standards and Requirements Evaluation of medical surge components of the tiered healthcare system Evaluation of medical surge components of the tiered healthcare system Develop adequate evaluation tools and methods Develop adequate evaluation tools and methods Develop an After Action Report (AAR) Develop an After Action Report (AAR) Specifics: Specifics: Coordination with Public Health Coordination with Public Health Risk Communication Risk Communication Medication Distribution Medication Distribution Surveillance Surveillance Laboratory Capacity Laboratory Capacity Volunteer Activation (ESAR-VHP) Volunteer Activation (ESAR-VHP) Staff Support Staff Support Communications Communications Healthcare System Triage and Admission Healthcare System Triage and Admission Incident Command System (Integration and Coordination) Incident Command System (Integration and Coordination)

7CDC PHIN Conference 2008 CDC Cooperative Agreement and Pan Flu Exercise Requirements Maryland State Pan Flu Operational Plan Maryland State Pan Flu Operational Plan Based Upon CDC evaluation Based Upon CDC evaluation Appendix 12: Overarching Exercise Objectives by Priority Area: Appendix 12: Overarching Exercise Objectives by Priority Area: Mass Vaccination Mass Vaccination Continuity of Operations Continuity of Operations Surveillance/ Lab Exercise Surveillance/ Lab Exercise Community Mitigation Community Mitigation Communications Communications Antiviral Distribution Antiviral Distribution Strategic National Stockpile (SNS) Medical Countermeasure Distribution Strategic National Stockpile (SNS) Medical Countermeasure Distribution

8CDC PHIN Conference 2008 Maryland Statewide Pan Flu Exercise Objectives DHMH Coordination/Command Center and Continuity of Operations Plan DHMH Coordination/Command Center and Continuity of Operations Plan Health and Medical Surge (Facilities, Personnel, Equipment and Supplies) Health and Medical Surge (Facilities, Personnel, Equipment and Supplies) Medical Surge – Alternate Care Sites Medical Surge – Alternate Care Sites Strategic National Stockpile / Receipt Staging and Storage Strategic National Stockpile / Receipt Staging and Storage Enhanced Surveillance Enhanced Surveillance Governor’s Wellmobiles Governor’s Wellmobiles Laboratory Surge Laboratory Surge Countermeasure Response Administration Countermeasure Response Administration EMS – Emergency Medical Dispatch EMS – Emergency Medical Dispatch EMS – Transport Diversion Protocol EMS – Transport Diversion Protocol EMS On-Scene Triage and Assessment Protocol EMS On-Scene Triage and Assessment Protocol

9CDC PHIN Conference 2008 Maryland Statewide Pan Flu Exercise Objectives Personal and Community Preparedness Personal and Community Preparedness Community Emergency Response Teams (CERT) Community Emergency Response Teams (CERT) Critical Infrastructure Critical Infrastructure Internal Countermeasure Distribution Internal Countermeasure Distribution Educational Facilities Educational Facilities Volunteer Activation Volunteer Activation Joint Information Center – Public Information Joint Information Center – Public Information Interoperable Communications Interoperable Communications Mass Fatality Management Mass Fatality Management Vulnerable Populations Vulnerable Populations

10CDC PHIN Conference 2008 Maryland 2008 Statewide Pan Flu Exercise Participants Open to all Federal, State and Local Partners: 56 Local Agencies 56 Local Agencies Emergency Medical Services Emergency Medical Services Emergency Management Agencies Emergency Management Agencies Local Health Departments Local Health Departments Law Enforcement Law Enforcement 25 State Agencies 25 State Agencies 4 Federal Agencies 4 Federal Agencies 50 Health Care Systems and Organizations 50 Health Care Systems and Organizations 12 State Hospitals / Residential and Day Program Service Providers 12 State Hospitals / Residential and Day Program Service Providers 8 Community Based Service Providers 8 Community Based Service Providers 8 Critical Infrastructure/Key Resources/Critical Manufacturing 8 Critical Infrastructure/Key Resources/Critical Manufacturing

11CDC PHIN Conference 2008 Maryland 2008 Statewide Pan Flu Exercise Participants Total Number of Exercise Personnel: Players4,000+ Players4,000+ Contractor Controller/Evaluators/Observers 50 Contractor Controller/Evaluators/Observers 50 Peer Controller/Evaluators/Observers100 Peer Controller/Evaluators/Observers100 Exercise Design and Development Exercise Design and Development DHS Target Capabilities: 29 of of 45

12CDC PHIN Conference 2008 CDC CRA Activities Pre-Exercise: Exercise Planning/Development Exercise Planning/Development CRA Access CRA Access T raining (open to all) T raining (open to all) Exercise: Just-In-Time Training Just-In-Time Training S upport for R eal-time D ata E ntry S upport for R eal-time D ata E ntry Situational Awareness / Data Reporting Situational Awareness / Data Reporting State Level Data Access State Level Data AccessPost-Exercise: Hotwash and After Action Report Hotwash and After Action Report

13CDC PHIN Conference 2008 Countermeasure Response Administration Exercise Objectives Establish and implement CRA to collect data: Establish and implement CRA to collect data: Offline stand alone scenario Offline stand alone scenario Online web interface (Real Time/Delay) Online web interface (Real Time/Delay) Assess CRA ease of use Assess CRA ease of use Track and report on antivirals dispensed at a public and private agency Points of Dispensing Track and report on antivirals dispensed at a public and private agency Points of Dispensing Track and report on community antiviral dispensing Track and report on community antiviral dispensing

14CDC PHIN Conference 2008 CRA Exercise Specific Activities CRA Activation CRA Activation Data Entry Data Entry Direct: Web based Direct: Web based Indirect/Off-Line: Delayed Upload Indirect/Off-Line: Delayed Upload Monitoring and Tracking Monitoring and Tracking Dispensing of Medications Dispensing of Medications Adverse Reactions to Antiviral Medications Adverse Reactions to Antiviral Medications

15CDC PHIN Conference 2008 Maryland CRA Participating Sites Howard County Health Department Hammond Middle School POD (Real-time Data Entry) POD in Howard County dispensing antivirals to head-of-household for surrounding community POD in Howard County dispensing antivirals to head-of-household for surrounding community Chateau Lake Ridge Community (Post-dispensing Data Entry) Community dispensing with limited social distancing Community dispensing with limited social distancing Chester River Hospital (Real-time Data Entry) Fixed POD dispensing antivirals to employees Fixed POD dispensing antivirals to employees City of Laurel (Real-time Data Entry) Community dispensing with voluntary Isolation and Quarantine Community dispensing with voluntary Isolation and Quarantine Note: Two sites anticipated using CRA

16CDC PHIN Conference 2008 CRA Data Entry

17CDC PHIN Conference 2008 CRA Evaluation Overall Exercise: CRA data collection and entry CRA data collection and entry Key Strengths: The “just-in-time” training was very successful and was a key to proficiency; The “just-in-time” training was very successful and was a key to proficiency; Data entry into the CRA application flowed well; Data entry into the CRA application flowed well;

18CDC PHIN Conference 2008 CRA Evaluation Key Strengths: Within a short amount of time participants were able to enter information; Within a short amount of time participants were able to enter information; Data entry into CRA described as simple and ‘intuitive’ by participants; Data entry into CRA described as simple and ‘intuitive’ by participants; (Data entry maybe labor intensive) (Data entry maybe labor intensive) Users were able to pull data and track progress; Users were able to pull data and track progress; CRA reports were useful in providing data of antivirals dispensed at the local and state level; CRA reports were useful in providing data of antivirals dispensed at the local and state level;

19CDC PHIN Conference 2008 CRA Evaluation Areas for Improvement: Ability to track individuals that present at a dispensing site but do not receive countermeasures; Ability to track individuals that present at a dispensing site but do not receive countermeasures; Ability to support Head-of-Household data collection; Ability to support Head-of-Household data collection; Support interoperability with other systems; Support interoperability with other systems; Not all regions of the state participated in CRA exercise activities; Not all regions of the state participated in CRA exercise activities;

20CDC PHIN Conference 2008 CRA Evaluation Recommendations: Expansion of CRA participation in the Public and Private Sectors; Expansion of CRA participation in the Public and Private Sectors; Continue to train hospitals and health departments on the CRA program; Continue to train hospitals and health departments on the CRA program; Increase recruitment for CRA access ; Increase recruitment for CRA access ;

21CDC PHIN Conference 2008 Suggested CRA Enhancement Pre-population and Uploading of Data Pre-population and Uploading of Data Health Department Personnel (State HAN) Health Department Personnel (State HAN) Private Sector Expanded Data Entry and Participation: Private Sector Expanded Data Entry and Participation: Healthcare Systems Healthcare Systems Public-Private Partnership Public-Private Partnership Critical Infra-structure/Key Resources/Critical Manufacturing Critical Infra-structure/Key Resources/Critical Manufacturing Essential Staff and Personnel Essential Staff and Personnel Expanded Application Expanded Application Fatality Registration Fatality Registration

22CDC PHIN Conference 2008 Maryland Future Activities DAX 2008 (Seasonal Influenza Vaccination Exercise) DAX 2008 (Seasonal Influenza Vaccination Exercise) Increase CRA Training and Access Increase CRA Training and Access All Maryland Participation All Maryland Participation 24 Counties 24 Counties Combination: Combination: Real-Time and Delayed Data Entry Real-Time and Delayed Data Entry On-Line Web Based vs Off-Line Data Entry On-Line Web Based vs Off-Line Data Entry Aggregate vs individual Data Entry Aggregate vs individual Data Entry Regional Clinic Integration and Coordination Regional Clinic Integration and Coordination

23CDC PHIN Conference 2008 Al Romanosky, MD, PhD Maryland Department of Health and Mental Hygiene Office of Preparedness and Response