Vulnerable Populations Pandemic Influenza Preparedness Tabletop Exercise Santa Clara County Public Health Department June 24, 2008

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 1

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 2

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 3

Objectives  By the end of this exercise, you should be able to: Describe your individual and your agency’s roles in the response to Pandemic Influenza Identify at least one gap in your agency’s existing Emergency Operations Plan (EOP) Contact the appropriate partnering agencies for assistance 4  

In the news… Human-to-human transmission of avian influenza has been reported by the Centers for Disease Control & Prevention (CDC) 5

Outbreak… 6

Today in San Jose... 7

DAY 1, 9:00 a.m. The beginning… A 47-year-old man from San Jose arrives at the emergency department (ED) at Valley Medical Center with fever, chills, cough and shortness of breath 8

 He is a prominent wildlife photographer who returned two days ago with his wife from an assignment in Nigeria Patient history 9

Bad decision… Last night, despite feeling feverish and tired, he attended an awards banquet with 200 of his colleagues 10

 He is evaluated in the Emergency Dept (ED)  Chest x-ray reveals pneumonia  A breathing tube is inserted (intubated) and placed on a ventilator due to severe respiratory distress  Just as he is moved to the Intensive Care Unit (ICU), his wife begins to complain of similar symptoms and registers as a patient in the ED DAY 1, 12:00 p.m. At Valley Medical Center 11

 His wife’s respiratory status severely deteriorates  She is urgently transferred to the ICU DAY 1, 11:00 p.m. The wife worsens 12

 The photographer suffers a cardiac arrest and cannot be revived  Meanwhile, his wife struggles to stay alive DAY 2, 8:30 a.m. Code blue! 13

 ICU physician concerned based on rapid onset of illness and couple’s travel history to Africa  Decides to notify the Santa Clara County Public Health Department  Orders an infectious disease (ID) consult DAY 2, 8:30 a.m. Is something wrong? 14

Break for discussion 15

1.What steps have you taken to protect you and your family for pandemic influenza or other disasters/emergencies? Examples:  Prepared emergency pan flu home kit  Understand how to care for a sick family member at home  Know where to receive accurate information about pan flu 2.Have you established a plan for childcare if schools are closed for:  4 weeks (moderate) to 12 weeks? (severe pandemic) 3.Does your neighborhood have a Community Emergency Response Team (CERT), or an active neighborhood association with an emergency coordinator? 4.Do you know where your vulnerable neighbors reside? Has your neighborhood planned how to assist them in an emergency? Personal Preparedness 16

Communication… 17

  Three of the new patients were on the same flight as the index (initial) patient and live in the surrounding area DAY 2, 2:00 p.m. Related cases Four more patients arrive at Valley Medical Center with severe flu-like illness 18

 A leading medical journal reports human bird flu cases in Eastern Europe  World Health Organization (WHO) reports that human-to-human transmission of avian influenza has occurred, but remains limited  WHO increases the pandemic influenza alert phase to 4 DAY 2, 3:30 p.m. In the rest of the world… 19

WHO Pandemic Flu Phases Inter-pandemic phase No new virus in animals, no human cases Low risk of human cases 1 Higher risk of human cases 2 Pandemic alert New virus causes human cases No or very limited human- to-human transmission 3 Increased human-to-human transmission 4 Significant human-to-human transmission 5 Pandemic Efficient and substained human- to-human transmission 6 20

DAY 3, 12:00 p.m Confirmation of new pandemic flu virus 21

DAY 3, 3:30 p.m. Breaking news! KNTV 11 news reports: 22

DAY 3, 4:30 p.m. Public Health Response  schools will be closed effective immediately  large public gatherings have been cancelled  all local agencies including hospitals are asked to implement their Pandemic Influenza Plans A press conference is called by SCC Health Officer, Dr. Fenstersheib to announce: 23

Public panic!!!  CADRE agencies begin receiving concerned calls from clients.  They are worried about getting ill and are asking how they can avoid the pandemic virus  Some are worried about how they are going to continue to receive services  Some clients are afraid to leave their homes  CADRE Network is activated 24

DAY 4, 1:00 p.m. Valley Medical Center 25

Break for discussion 26

1.At your agency, what measures will you take to limit the spread of the virus  For clients?  For staff? 2.How can your agency disseminate critical information to the clients you serve?  Currently (pre-pandemic)  During a pandemic 3.Have you identified which of your clients are at greatest risk of getting ill? Agency Preparedness 27

Detection… 28

DAY 4 Epidemiological Investigation Centers for Disease Control SCC Public Health DeptCA Dept of Public Health Virus sample sent to CAPHD for analysis Specimen confirmed for pandemic influenza. Sample is sent to CDC for final confirmation. Specimen is confirmed as a new pandemic influenza strain SCCPHD & CADPH or notified Local and State response is taken 29

 People who also attended the awards banquet begin to seek hospital care  In addition to the index case, two more patients with suspected pandemic influenza have died DAY 5, 10:00 a.m. The illness spreads 30

Overwhelmed hospitals triage patients as they arrive, admitting only the most ill. The vast majority must return home to cared for by family members DAY 5, 4:00 p.m. Hospitals Reach Surge Limit 31

Influenza Care Centers Open  Santa Clara County Health Officer orders the first ICC to open. The ICC will receive patients that are too sick to be at home, but do not meet criteria for hospital admission. Capacity of an ICC is 450 patients. 32

 Worldwide  Cases reported in East Asia, Eastern Europe and, most recently, in Africa  Mortality (death) of patients with pandemic influenza in Asia exceeds 5%  WHO declares an increase to pandemic phase 5 for influenza DAY 6, 3:00 p.m Increase to WHO phase 5 33

Break for discussion 34

1.Does your agency have an emergency operations plan?  Who or how, does your agency activate your  What are your activation procedures and staffing plan for emergency situations? 2.What interagency arrangements have been made for sharing resources in your community? 3.How are you going to provide services to home-bound individuals? Agency Response 35

Crisis & Long Term Effect 36

 Two San Jose pharmacies have experienced burglaries, presumably by persons looking for Tamiflu®  Law enforcement unable to respond immediately because of unprecedented absenteeism among officers DAY 7 Breakdown of infrastructure 37

 Some healthcare workers are afraid to come into work  Essential services such as trash collection, utilities repair and public safety agencies are reporting up to 30% absenteeism  Many businesses encourage workers to telecommute or work flexible hours Day 8 Absenteeism Crisis 38

 Evidence supports person- to-person transmission  Almost 1,000 suspected cases statewide  75 have died, including numerous healthcare workers and first responders DAY 14 Update 39

DAY 14 Mass fatality concerns 40

 WHO declares an influenza pandemic, phase 6  In the U.S., public health officials still struggling to control the spread of pandemic influenza  Public health system, including hospitals, remains overwhelmed DAY 16 Pandemic declared 41

 Local businesses are suffering from lack of workers and customers  Poultry consumption down because consumers are afraid of getting sick from eating chicken Emerging economic consequences DAY 20 42

 Forecasters predict that epidemic will continue for several more months and result in over 1.8 million deaths nationwide  Santa Clara County deaths could surpass 36,000  Estimated nationwide economic impact will exceed $100 billion DAY 20 Forecasts 43

Break for discussion 44

1.Does your agency have a plan for staff absences unique to a pandemic?  Time off/ leave pay to care for family, or when employee is home in isolation or quarantine?  Or return to work policies specific to a pandemic? 2.Are there any client related supplies that you could potentially stockpile to prepare for a pandemic? Long Term Planning & Response 45

End of Pandemic Flu Scenario Thank you!! 46