1. Module 3 Summary & Wrap Up
Discipline and agency role(s) typically change as investigation progresses.
Lead agencies work with response partners to develop and adjust investigation plan.
Supporting agencies retain their authorities and responsibilities.
An effective initial informational conference calls can help launch an MJO investigation.
Lead agency is determined based on several factors including: authorities, expertise, and resources.
Multijurisdictional foodborne outbreaks are typically a nested series of investigations
LHDs are still the lead agency for investigation activities within their jurisdiction.
Each agency retains their authorities and responsibilities
Lead agencies typically play a coordinating role to ensure information is effectively shared.

2. Learning Objectives
Recognize the stages of multijurisdictional outbreak (MJO) responses
Identify best practices used to effectively participate in MJO during each stage
Coordination
Communication
Leadership
Practice interpersonal communication and problem solving skills
This is what we wanted to accomplish during today’s training.
We shared best practices to help better define what the key terms of coordination, communication, and leadership mean within the context of multi-jurisdictional foodborne illness outbreak investigations.
The small and large group discussions and activities gave us all opportunities to practice our communication and problem solving skills.

3. Stages of Multi-Jurisdictional Foodborne Outbreak Responses
Investigations can get a little more complicated as incident size and scope increases and more and more agencies are added to the investigation team.
In this module with were working in the first two levels of the response. Routine procedures, office communications, and working relationships may or may not be sufficient when LHDs receive multiple signals that something is brewing in their communities.
LHDs have invested in emergency preparedness to have increased capacity to effectively manage these situations when needed:
Emergency communications – operational and public risk communications
Coordination – assessing, planning, partnering with multiple agencies
These efforts have made LHDs and response partners more robust and resilient – increased capacity to handle a wide range of challenging situations.
Foodborne Outbreaks give agencies the opportunity to practice using these capacities – don’t keep them on the shelf waiting for the big one. If you don’t use it you lose it.

4. Multi-Disciplinary Coordination
Incident
Detection
Incident
Resolution
Epidemiology / Communicable Disease
Use this slide to reinforce Coordination, Communication and the 4 Guiding Principles
Foodborne outbreaks are typically multi-disciplinary
Outbreaks are most efficiently investigated as close to the source as possible – surveillance is local, LHDs are front line.
As incident complexity and size increases – transition in command/lead agency often changes to manage resources
Rapid information sharing
Early on – conference calls focus on epi/lab information
Later on – food regulatory issues.
Include staff from all disciplines to ensure the entire team has a complete picture – “situational awareness”
Not every MJO starts as a recognized public health emergency. The slowly building ones can sneak up on you if you aren’t careful.
Environmental Health / Food Regulatory
Laboratory – Clinical and Food

5. Module 1: STEC 0103 Outbreak Epidemic Curve
We have a lot of unanswered questions at this point.
Is this a historical event or is there ongoing exposure? Knowing what the normal background level of disease is in your community at any point in time can make a big difference.
We don’t know much about the complaints and there aren’t any obvious links between the laboratory confirmed cases. They are over a month old know to the investigative trail is growing cold. It often takes 2-3 weeks to confirm, type and PFGE test STECs that are not 0157:H7. A month is a bit long. Are there ways we can reduce the time that samples are in the pipeline?
Are the complaints with bloody diarrhea STEC 0103? Is this random fluctuations in bloody diarrhea in the community that previously went undetected or are we noticing the early phases of something bigger?

6. Module 1: Multi-disciplinary Collaboration
Discipline
Individual
Module 1 started us off with a relatively routine investigation of a cluster of laboratory confirmed illnesses and an increased number of complaints of unconfirmed illness.
The response team was the core foodborne illness individuals and disciplines using their standard operating procedures.
Effective working relationships are key for prompting responding to “signals” of illnesses in the community that your surveillance systems detect
Health care providers and private laboratories
LHD staff – PIO, HO, EH, CD, Epis
State agencies – MDARD, MDCH, DOC, MSP,…
But there were indicators that the situation could get worse. And it did.

7. Module 2: STEC 0103 Outbreak Epidemic Curve
A week went by and the outbreak expanded.
More confirmed cases but still 2-3 weeks ago (how many more are in the pipeline?)
A surge in recent unconfirmed cases – the result of our communications with health care providers and labs or an indication of increased exposures taking place in the community?
Case definitions helped to sort out the level of certainty in our knowledge about various cases.
People, agencies, and the media are now coming to you for updates.
Does your agency have a plan to handle that increased workload (summarizing data, creating and delivering talking points in a clear and consistent manner)?
Objective: Protect the investigation team so they can stay focused on what they do best. Bring in others who have the training and skill to manage these non-routine tasks.
Increased potential for the “Fog of war” – information from multiple sources is coming in and can be difficult to tabulate to have and communicate an accurate “situational awareness”. Example: different tables reporting different case counts.
Implications? LHDs definitely are moving out of routine response procedures and may need to activate various portions of their emergency procedures to effectively manage this expanding incident. Leadership will need to re-prioritize workloads and ramp up the investigation.

8. Module 2: Agency Mobilization
Discipline
Individual
In module 2, we saw a large part of the agency being mobilized to respond to the incident and initial notifications were made if they hadn’t been made in Module 1. As the investigation team grows from you, to you and you coworkers within your discipline, to your entire agency, to multiple agencies the number and complexity of tasks related to communication and coordination increases.
Individuals – stay focused on what is my job within the response, need to reprioritize workload as new information becomes available, recognize obstacles and opportunities when they arise.
Disciplines – reprioritizing, supervisors need to become less doers and more directors
Agency – assessing rapidly changing situations, adjusting current response plans while anticipating future needs, mobilizing resources.
Agency

9. Module 3: STEC 0103 Outbreak Epidemic Curve *
This slide only summarizes the information contained in the injects for the first two tables. Information from all 5 tables would have been “off the charts”.
In Module three the focus shifted from a single LHD perspective to a statewide perspective.
We discovered on the initial informational conference call that there was a lot more going on than any one agency was aware of.
Each agency was aware of what was going on in their jurisdiction, but we didn’t have a shared understanding until we started sharing information
The initial conference call was a first step in what would need to be sustained and possibly expanded communications.
* Tables 1 & 2 Only

10. Module 3: Multi-Jurisdictional Outbreak Investigation Team
Multi-agency
Discipline
Individual
In Module 3 we explored some of the reasons why most after action reports of large scale multi-agency responses indicate that key problems were communication and coordination. As the investigation team grows from you, to you and you coworkers within your discipline, to your entire agency, to multiple agencies the number and complexity of tasks related to communication and coordination increases.
Individuals – stay focused on what is my job within the response, need to reprioritize workload as new information becomes available, recognize obstacles and opportunities when they arise.
Disciplines – reprioritizing, supervisors need to become less doers and more directors
Agency – assessing rapidly changing situations, adjusting current response plans while anticipating future needs, mobilizing resources to assume administrative and coordination responsibilities so the core disciplines can stay focused on their jobs.
Agency

11. A Predictable Planning Process Can Bring Order to Chaos
All Hazards Task List
Assess the situation
Develop / review your investigation plan and
update response objectives
Communicate with key staff, agencies / organizations and affected jurisdictions
Address requests for assistance and
information
Initiate / continue public risk communication activities as appropriate
Stay apprised of legal issues
Document all response activities.
The ICS Planning P
In each module we used the All Hazards Task List to focus our discussions and to create a predictable pattern of assessing, planning, implementing communicating.
Not all that different than the ICS Planning P. The key is to identify what planning structure your agency has developed and learn how to use it so you can work effectively with your team during future responses.

12. Leveraging Existing Preparedness Resources
Your agency likely has planned for this type of situation
Can you speak fluent “Emergency Preparedness”?
Choose the right tool for the job
All Hazards Multi-Jurisdictional Response Task List
MJO Response Checklist – 2 pages
Over the years, EPCs and other LHD staff have developed various contingency plans for various scenarios – with the objective of developing robust preparedness programs that can be used during a broad range of incidents (i.e., all hazards preparedness). This includes strategies for contacting specific groups and subpopulations within your jurisdiction in times of emergencies.
Speaking fluent “Emergency Preparedness” – like any dialect, the Emergency Preparedness discipline has its own terminology that you’ll need to learn – what is the difference between a Plan, Policy, an Procedure or an Annex, Appendix, and Attachment? Once you begin to crack the code you can begin to more effectively learn for yourself how you can put these tools to work and not “Reinvent the wheel”. Example: how many contact lists does your agency maintain?
The key is to know what tools are available to you and which tool will work best for your specific situation. Example:
All hazards response task list is general (on page lots of white space) – great for keeping focus on the big picture components of a response.
MJO Response Checklist is 2 pages with lots of details – specific for lead and supporting agencies. A good tool for busy leaders to check and make sure all the nuts and bolts are being addressed. Could be helpful in identifying tasks needed to be delegated.

13. Effective Communications
Are based on accurate “situational awareness”
Develop a plan with clear objectives
Then communicate
Routine information sharing
Initial written reports
Conference calls
Public risk communications
That is why each module started with “Assess the situation” – what has changed. Then the team had to be clear on what their plan for that time period was

14. Leadership at Multiple Levels
Federal
State
Local
Top Down
Bottom Up
Agency
Discipline
Individual
We explored how effective MJO investigations require leadership at all levels of the response to appropriately share resource and expertise
Individual level - individuals who know how they fit in to the overall response effort, recognize what needs to get done and some of the pitfalls that could prevent that from happening so they can take appropriate actions
Discipline level –understand the local context and the core team’s strengths and limitations, and share information or cooperate to give other disciplines what they need when they need it to do their job,
Agency level – maintain overall situational awareness of where the outbreak is and where it might be heading so they can share information with the public and response partners to prevent illnesses and save lives. To do this much of their job is to “protect the core team” from the distractions that can suck the life out of an investigation by expanding the team to include others skilled at the additional tasks – documentation, communication, analysis, public relations.

15. Parting Thoughts
Emergencies are run on the strength of the response team’s relationships.
Effective plans, procedures, and processes never hurt either.
Training is an ongoing process – thanks for investing a day with us!

16. Wrap Up & Evaluations Questions or comments from participants
Suggestions for next year’s training
Evaluations
Have safe trip home