1. Interactive Event Condensed Table Top Exercise For San Joaquin County Adapted from an exercise by CDFA, CDHS, FDA and others

2. Monday June 5 9-11:00pm – San Joaquin General Hospital ER receives seven unrelated children with difficulty reading, slurred speech & choking on evening meal. 9-11:00pm – San Joaquin General Hospital ER receives seven unrelated children with difficulty reading, slurred speech & choking on evening meal. Presumptive diagnosis is botulism Presumptive diagnosis is botulism What happens next? What happens next?

3. Tuesday June 6 8:00 am – Most ER’s in San Joaquin and Sacramento Counties are seeing an increase in pediatric patients & some adults. Similar symptoms reported, including dizziness, fatigue, dry mouth, and double vision. 8:00 am – Most ER’s in San Joaquin and Sacramento Counties are seeing an increase in pediatric patients & some adults. Similar symptoms reported, including dizziness, fatigue, dry mouth, and double vision. 10 am Conference Call Scheduled – Who needs to be there? 10 am Conference Call Scheduled – Who needs to be there?

4. Work Group Discussion # 1 Based on information provided discuss: Based on information provided discuss: What is going on? What is going on? Any suspect cause or causes? Any suspect cause or causes? Who are involved in response? Who are involved in response? Record answers on flip chart Record answers on flip chart

5. Inject 1: Tuesday, June 6, 9:00am First Cases – Additional cases reported-

6. First Conference Call: Tuesday, June 6, 1100 hours Roll-call Roll-call County public health (San Joaquin and Sacramento counties), CDPH-DCDC, CDPH- FDB, CDC, FDA County public health (San Joaquin and Sacramento counties), CDPH-DCDC, CDPH- FDB, CDC, FDA Anyone Missing - If so, How do you reach out? (Are your contact lists current?) Anyone Missing - If so, How do you reach out? (Are your contact lists current?)

7. First Conference Call Tuesday, June 6, 11:00 am Review descriptive epidemiology Review descriptive epidemiology Many cases are children Many cases are children Some of the adult cases work in schools Some of the adult cases work in schools No common event reported No common event reported Tentatively classified as food-borne Tentatively classified as food-borne Local and state epidemiologists are working round the clock to conduct interviews Local and state epidemiologists are working round the clock to conduct interviews The media is calling county and state public health departments seeking information The media is calling county and state public health departments seeking information Concern expressed that this was an intentional contamination event Concern expressed that this was an intentional contamination event

8. Summary of content of case investigation form for neurologic illness Demographic information Demographic information Signs and symptoms Signs and symptoms Past medical and social history Past medical and social history Hospital info Hospital info Physical exam Physical exam Lab test results Lab test results Initial treatment Initial treatment Discharge information Discharge information

9. Summary of content of case investigation form for neurologic illness Risk exposure questions Risk exposure questions Pertain to 2-week period prior to onset Pertain to 2-week period prior to onset Describe your job/volunteer duties Describe your job/volunteer duties Anyone else at your workplace have similar symptoms? Anyone else at your workplace have similar symptoms? Do you know anyone else with similar symptoms Do you know anyone else with similar symptoms Travel? Travel? Public functions attended? Public functions attended? Types of transportation used Types of transportation used

10. Summary of content of case investigation form for neurologic illness Food and beverage questions Food and beverage questions Types of food establishments where food consumed Types of food establishments where food consumed Time and place, food consumed for each Time and place, food consumed for each Any free food samples? Any free food samples? Any supplements? Any supplements? Unpasteurized products? Unpasteurized products? Mail order foods? Mail order foods? Water sources Water sources

11. Tuesday June 6 at 3:00 pm Number of ill is rising rapidly Number of ill is rising rapidly Law enforcement has been informed of possible tampering Law enforcement has been informed of possible tampering Largest number of ill are in 5-18 year old age group Largest number of ill are in 5-18 year old age group Hypothesis-generating interviews indicate that the common exposure of most of the children was eating lunch at school Hypothesis-generating interviews indicate that the common exposure of most of the children was eating lunch at school Some adults report eating lunch at school, others ate at a deli chain that serves the Sacramento area Some adults report eating lunch at school, others ate at a deli chain that serves the Sacramento area Epidemiologists are reviewing school lunch menus for schools of affected children and developing a questionnaire Epidemiologists are reviewing school lunch menus for schools of affected children and developing a questionnaire

12. Wednesday June 7 Some patients experiencing respiratory difficulty. Additional respirators requested by hospitals. Some patients experiencing respiratory difficulty. Additional respirators requested by hospitals. Number of ill now exceeds 500. Additional antitoxin requested from CDC. Number of ill now exceeds 500. Additional antitoxin requested from CDC. Worried parents are bringing children to emergency rooms that are not seriously ill. Worried parents are bringing children to emergency rooms that are not seriously ill. 911 lines are overloaded 911 lines are overloaded 2:30 pm - 3 deaths reported 2:30 pm - 3 deaths reported Epi results indicate milk is possible vehicle. Conference call scheduled for 3 pm. CDFA and FBI invited to join. Epi results indicate milk is possible vehicle. Conference call scheduled for 3 pm. CDFA and FBI invited to join.

13. Work Group Discussion # 2 Based on information provided discuss: Based on information provided discuss: Next steps? Next steps? What information should be provided to the public? What information should be provided to the public? What is my organization’s role? What is my organization’s role? How do I provide assistance if not directly involved? How do I provide assistance if not directly involved? Who is involved in response? Who needs to be involved, but isn’t? Who is involved in response? Who needs to be involved, but isn’t?

14. Inject 2: Conference call Wednesday June 7 at 3 pm Epidemiology reviewed Epidemiology reviewed

15. Third Conference Call Thursday June 8, 0630 Roll-Call Roll-Call New information New information In San Joaquin County most victims had consumed milk at schools In San Joaquin County most victims had consumed milk at schools Low fat milk in ½ pints were consumed at schools Low fat milk in ½ pints were consumed at schools Other victims had consumed either low fat or reduced fat milk Other victims had consumed either low fat or reduced fat milk Whole milk did not appear to be implicated Whole milk did not appear to be implicated Incriminated milk had one sell-by date Incriminated milk had one sell-by date Incriminated milk had one plant ID# Incriminated milk had one plant ID# Plant # belongs to a new plant in San Joaquin County Plant # belongs to a new plant in San Joaquin County (Note: Next 5 Slides are Reference Slides for Badger Creek Milk)

16. Reference Slide 1: Fictional Milk Processor Name: Badger Creek Milk Co. Name: Badger Creek Milk Co. Location: Lodi, CA Location: Lodi, CA Company goal: Become a leader in the California organic milk market Company goal: Become a leader in the California organic milk market Plant Description: Moderate sized, Grade A facility. Fluid milk bottling with an on-site evaporator Plant Description: Moderate sized, Grade A facility. Fluid milk bottling with an on-site evaporator

17. Reference Slide 2: Fictional Milk Processor Badger Creek Milk Inc. Milk Supply: Purchases milk from 25 local organic dairies, and a California based dairy cooperative Milk Supply: Purchases milk from 25 local organic dairies, and a California based dairy cooperative Customers Include: Customers Include: 1. California State University, Sacramento 2.Stockton, Tracy, Lodi, Manteca, and Elk Grove Unified School Districts 3.National made to order sandwich chain (“Deli”) Surplus cream and condensed sold to large Surplus cream and condensed sold to large San Diego manufacturing plant

18. Reference Slide 3: Badger Creek Milk Co., Plant Diagram

19. Reference Slide 4: Low Fat Milk made for Schools and Deli Sunday June 4, 11:00 pm: Used 17,200 gal of raw milk Silo A (uncontaminated) and 1,041 gallons of condensed to produce: Sunday June 4, 11:00 pm: Used 17,200 gal of raw milk Silo A (uncontaminated) and 1,041 gallons of condensed to produce: 1,255 gal of cream 1,255 gal of cream 16,985 gal of low-fat milk 16,985 gal of low-fat milk (160,000 half pints for schools) (111,776 half pints for Deli)

20. Reference Slide 5: Production Details Milk received 7 days/week, used within 24 to 48 hours. Milk received 7 days/week, used within 24 to 48 hours. All school districts purchase half pints of Lowfat milk All school districts purchase half pints of Lowfat milk Deli purchases half pints of whole milk, reduced fat milk, and lowfat milk Deli purchases half pints of whole milk, reduced fat milk, and lowfat milk Half pints are produced Sunday and Wednesday (distributed Monday and Thursday) Half pints are produced Sunday and Wednesday (distributed Monday and Thursday)

21. Third Conference Call Thursday June 8 0630 Topics during call: Topics during call: Any remaining half-pints of milk must be embargoed immediately. How will this be done? Any remaining half-pints of milk must be embargoed immediately. How will this be done? Might consumers have this product in their refrigerators? Might consumers have this product in their refrigerators? The good news is that only one plant appears involved (at this time). Consumers who do not have this brand (and sell by date) need not be concerned. The good news is that only one plant appears involved (at this time). Consumers who do not have this brand (and sell by date) need not be concerned. How do you convince consumers that the problem is not more widespread? How can we be sure that no other product is contaminated? (Whole milk involved?) How do you convince consumers that the problem is not more widespread? How can we be sure that no other product is contaminated? (Whole milk involved?)

22. Inject 3: Work Group Discussion # 3

23. Fourth Conference Call Thursday June 8, 11:30 Roll-Call - Topics for this call Roll-Call - Topics for this call Situation update Situation update What do you do with the remaining suspect milk (in plant, at distributors, at retail, in homes, in disposal bins at schools or elsewhere)? What do you do with the remaining suspect milk (in plant, at distributors, at retail, in homes, in disposal bins at schools or elsewhere)? Collection and disposal issues Collection and disposal issues How can you handle uncontaminated yet unwanted milk from the unaffected dairies and plants? How can you handle uncontaminated yet unwanted milk from the unaffected dairies and plants? Are there safety precautions necessary when handling contaminated milk or containers? Are there safety precautions necessary when handling contaminated milk or containers? What needs to decontaminated and how? What needs to decontaminated and how? How can it be destroyed? How can it be destroyed? (Note: Situation update is summarized next 2 slides)

24. Info Presented on Call – Deaths by City up to 10:30 AM on June 8th CityWednesday by 6:00 PM Thursday by 10:30 AM Total Elk Grove20210230 Stockton37347384 Tracy10225235 Lodi11144155 Sacramento3182185 Total8111081189

25. Deaths by Age-Group and City City/Age<5yrs5-18yrs>18 yearsTotal Elk Grove3711281230 Stockton4231527384 Tracy1419328235 Lodi259832155 Sacramento357125185 Total1217752931189

26. Inject 4: Work Group Discussion (4)

27. LABORATORY RESPONSE & RECOVERY

28. RESPONSE TO EVENT Who calls in the Labs & What Lab support is needed? Who calls in the Labs & What Lab support is needed? Capability : Capability : Who can handle & analyze samples? Who can handle & analyze samples? Which Food Testing Laboratories ? Which Food Testing Laboratories ? Capacity: Capacity: How many Samples? How many Samples? Which Product(s)? Which Product(s)?

29. RESPONSE –con’t Based on Current information: Based on Current information: Capability : Capability : Only 5 Food testing labs available in CA can analyze milk samples. Only 5 Food testing labs available in CA can analyze milk samples. Lab Locations: Lab Locations: Davis (CAHFS), Alameda (FDA), Irvine (FDA), Davis (CAHFS), Alameda (FDA), Irvine (FDA), Fresno (County PHL), Richmond (CDHS-FDLB) Fresno (County PHL), Richmond (CDHS-FDLB)

30. RESPONSE –con’t Capacity: Capacity: Davis, Fresno, Richmond, Irvine can analyze 25 samples in a 24hrs period (100/day for 4 days) Davis, Fresno, Richmond, Irvine can analyze 25 samples in a 24hrs period (100/day for 4 days) Alameda Lab has same capacity as other labs, but Instrument is down & Won’t be back on- line for 5 days. (from 6/13 Capacity will be 125 samples a day) Alameda Lab has same capacity as other labs, but Instrument is down & Won’t be back on- line for 5 days. (from 6/13 Capacity will be 125 samples a day)

31. RECOVERY What Lab support will be needed to work thru this phase? What Lab support will be needed to work thru this phase? Assume Capacity is same Assume Capacity is same Do we need more labs? Do we need more labs? If so – How will you obtain or access additional Laboratories? If so – How will you obtain or access additional Laboratories? What Lab networks are out there? What Lab networks are out there?

32. Inject 5 -Work Group Discussion Lab Questions “?’s”

33. Summarize Info Group Discussion Group Discussion

34. Badger Creek Milk Inc. Event Overview 2,500 gallons of raw milk in a dairy farm tank was contaminated with 2 grams pure botulinum toxin, type A 2,500 gallons of raw milk in a dairy farm tank was contaminated with 2 grams pure botulinum toxin, type A