Napa County Public Health is holding a tabletop exercise on 10/28/13 to discuss the response to an e. Coli outbreak. This is in conjunction with the CA Dept of Public Health and anticipation of the upcoming statewide functional exercise. Slides prepared by The Abaris Group

1. Napa County
2013 Medical Health
Tabletop Exercise
October 28, 2013
10:00 AM – 2:00 PM
1

2. Welcome and Introductions
The 2013 Statewide Medical and Health
Exercise is sponsored by:
• California Emergency Medical Services Authority
• California Department of Public Health
In collaboration with:
•
•
•
•
•
California Hospital Association
California Association of Health Facilities
California Primary Care Association
California Emergency Management
Response partners representing local health
departments, emergency medical services, public
safety and healthcare facilities
2

3. Welcome and Introductions
 Introduction of Exercise Planners and Facilitators
 Housekeeping Issues
 Agenda Review
3

4. Exercise Purpose
To evaluate current response concepts, plans,
and capabilities related to a medical surge of
patients from a foodborne illness outbreak in the
local community.
The exercise will focus on the coordination of
surveillance activities and health system
capabilities anticipated when managing a medical
surge among community healthcare partners.
4

5. Exercise Target Capabilities
 Public Health Epidemiology & Surveillance
 Emergency Public Information & Communications
 Emergency Operations Center Management &
Medical Surge
5

6. Tabletop Exercise Objectives
Evaluate ability to:
 Activate surge plans
 Implement the Incident Command System
 Request, distribute, track and return resources
in accordance with the California Public Health
Emergency Operations Manual (EOM)
 Coordinate risk communication
6

7. Tabletop Exercise Objectives
Evaluate ability to:
 Issue public information notifications
 Conduct surveillance and epidemiological
investigations
 Implement necessary control measures to stop
further cases of illness or disease
7

8. Tabletop Exercise Scenario
Scenario:
 Napa residents are presenting to healthcare
providers with abdominal pain and bloody
diarrhea in above average numbers
 Some patients are needing hospital and ICU
admission
 A foodborne disease is suspected
8

9. Subject Matter Experts
• Dr. Jennifer Henn, Epidemiologist
• Napa County Public Health
• Dr. Karen Smith, Health Officer
• Napa County Public Health
• Jahniah McGill, Registered Environmental Health
Specialist
• Environmental Health, Napa County
9

10. EPIDEMIOLOGY
Dr. Jennifer Henn
Epidemiologist
Napa County Public Health
10

11. EPIDEMIOLOGY OF A
FOODBORNE ILLNESS
11

12. FOODBORNE ILLNESSES
• Caused by ingestion of contaminated food
• Can also be spread via other modes
• Gastrointestinal tract symptoms
 Nausea & vomiting
 Diarrhea
 Abdominal pain
• Nonspecific symptoms outside the G.I. tract
• Children under 5, older adults and medically fragile
are most vulnerable
12
12

13. FOODBORNE ILLNESSES
An estimated 1 in 6 suffer from foodborne illnesses
annually leading to an estimated:
 48 million cases
 128,000 hospitalizations
 3,000 deaths
 $35 billion in medical costs & lost productivity
>1,000 outbreaks detected annually
(Painter JA, Hoekstra RM, Ayers T, Tauxe RV, Braden CR, Angulo FJ, et al. Attribution of foodborne
illnesses, hospitalizations, and deaths to food commodities by using outbreak data, United States, 1998–
2008. Emerg Infect Dis [Internet]. 2013.)
13
13

14. DAILY DOUBLE
What foodborne disease do these foods have in
common?
•
•
•
•
•
•
Raw sprouts
Pizza
Cookie dough
Fresh spinach
Ground beef patties
Romaine lettuce
14
14
14

15. SHIGA TOXIN PRODUCING E. COLI
15

16. E. COLI O157:H7
 First recognized as pathogen in 1982
 First outbreak traced to hamburgers
 USDA banned sale of raw meat containing E. coli
O157:H7 in 1994
 Many outbreaks now linked to contaminated raw
vegetables (e.g., sprouts, leafy greens) and other
contaminated ready to eat foods
16

17. STEC OUTBREAKS
2012
Multistate Outbreak of Shiga Toxin-producing
Escherichia coli O157:H7 Infections Linked to Organic
Spinach and Spring Mix Blend
Multistate Outbreak of Shiga Toxin-producing
Escherichia coli O145 Infections
Source not identified
Multistate Outbreak of Shiga toxin-producing
Escherichia coli O26 Infections Linked to Raw Clover
Sprouts at Jimmy John's Restaurants
17

18. STEC OUTBREAKS
2011
Multistate Outbreak of E. coli O157:H7 Infections
Linked to Romaine Lettuce
Outbreak of Shiga toxin-producing E. coli O104 (STEC
O104:H4) Infections Associated with Travel to
Germany (and consumption of raw sprouts)
Multistate Outbreak of E. coli O157:H7 Infections
Associated with Lebanon Bologna
Multistate Outbreak of E. coli O157:H7 Infections
Associated with In-shell Hazelnuts
18

19. E. COLI CONTAMINATION
AN EXAMPLE
 Multistate E. coli O157:H7 outbreak linked to baby
spinach in 2006 (205 cases, 102 hospitalizations, 3
deaths)
 Outbreak strain isolated from both cattle and feral swine
feces near spinach field
 Spinach from 1 field with E. coli
contamination mixed with spinach
and lettuce from other farms at
central processing plants
19

20. CONTAMINATION
AN EXAMPLE
Feral pigs
had access
to both cattle
and spinach
fields
Surface water
used for
irrigation
potentially
contaminated
with E. coli
20

21. E. COLI AND MEDICAL SURGE
AN EXAMPLE
 Outbreak of E. coli O104:H4 in 2011
– 3,816 cases in Germany; 54 deaths
– 845 (22%) involved Hemolytic Uremic Syndrome (HUS)
 Hospitals in most affected areas of Germany experienced
large influx of patients with HUS and other complications
due to E. coli infection
– Doubled number of staff
– Tripled machines for dialysis and plasma exchange
21

22. E. COLI AND MEDICAL SURGE
AN EXAMPLE
Video news clip:
http://www.bbc.co.uk/news/world-13696131
22

23. SHIGA TOXIN PRODUCING E. COLI
 Common reservoirs = cattle and other ruminants
 Vehicles in past outbreaks = ground beef, petting zoos, raw
vegetables and fruit, unpasteurized apple cider, water, etc.
 Growth requirements = facultative anaerobe, nonsporulating bacterium
23

24. E. COLI - EPIDEMIOLOGY
 Mode of Transmission
 Ingestion of food contaminated by traces of feces or direct
contact with animals and their environment
 Incubation Period
 Range from 2-10 days after exposure; median 3-4 days
 Period of Communicability
 When the bacteria is being excreted
 1 week or less (adults) or up to 3 weeks (children)
24
24

25. SHIGA TOXIN PRODUCING
E. COLI (STEC)
 Some E. coli bacteria produce shiga toxin
 When shiga toxin enters the bloodstream it
can damage the red blood cells
 Severity of illness ranges from mild diarrhea
to life threatening HUS
25
25

26. CLINICAL SYMPTOMS AND
TREATMENT OF STEC
INFECTIONS
Dr. Karen Smith
Health Officer
Napa County Public Health
26

27. SYMPTOMS
Symptoms of E. coli infection:
 Watery and often bloody diarrhea
 Abdominal cramping
 Abdominal pain
 Little or no fever
Most people will recover within 5 to 10 days
27

28. HEMOLYTIC UREMIC SYNDROME
(HUS)
 Life threatening condition that often
requires ICU treatment
 Triad of hemolytic anemia,
thrombocytopenia, and acute renal failure
 Often requires blood transfusions and
dialysis during acute phase
28

29. HEMOLYTIC UREMIC SYNDROME
(HUS)
 On average, HUS occurs in ~6% of E. coli
patients
 Case fatality rate of 3-5%
 Most cases of HUS occur in children under 5
 Use of antibiotics and anti-diarrheal
medication to treat E. coli infection increases
risk of HUS
29

30. DIALYSIS
 Average length of dialysis for patients with HUS due
to E. coli infection is 5-7 days (but can vary widely)
 Peritoneal dialysis widely used for pediatric patients
 Hemodialysis also suitable for children - may be
preferable in patients with severe abdominal pain
30

31. MANAGEMENT OF HUS
Successful management of HUS includes:
• Fluid therapy
• Management of acute renal failure
- ~50% of HUS patients require dialysis
• Blood and/or plasma transfusion
- Most children require packed RBC transfusion
• Management of hypertension
• Nutritional support and pain management
31

32. STEC – SPECIAL CONSIDERATIONS
 Most E. coli related HUS cases seen in children
< 5, but elderly and immunocompromised are
also at increased risk for HUS
 Elderly patients at higher risk for E. coli blood
stream infection (bacteremia) and may develop
additional complications due to presence of other
illnesses
32

33. FOODBORNE
OUTBREAK RESPONSE
Dr. Jennifer Henn
Epidemiologist
Napa County Public Health
33

34. OUTBREAK INVESTIGATION GOALS
 Identify all cases
 Find a common exposure
 Determine cause
 Stop the exposure
 Prevent future cases
 Notify providers
 Inform the public
34
34

35. A COORDINATED RESPONSE
Public Health
Foodborne Illness
Response Team
Laboratory
Environmental
35
Health
35

36. PUBLIC HEALTH RESPONSE ROLE
Public Health Nurses and Disease Investigators
• Interview patients
• Collect clinical specimens from patients
• Administer questionnaires for epidemiologic
studies
• Advise patients on how to prevent spread of
illness
• Provide public health education & guidance
(i.e., health advisories and health alerts)
36
36

37. PUBLIC HEALTH RESPONSE ROLE
Epidemiologists
• Analyze data from pathogen-specific
surveillance and identify clusters/outbreaks
• Characterize cases by time, place, and person
• Plan epidemiologic studies
• Interview cases and healthy controls
• Analyze and interprets results of epidemiologic
studies
37

38. PUBLIC HEALTH LABORATORY
RESPONSE ROLE
Public Health Laboratory staff
• Analyze clinical, food, and environmental
specimens
• Interpret test results and “fingerprint” strains
• Advise about tests and collection, handling,
storage, and transport of specimens
• Coordinate additional testing by partner labs
38

39. WHO ARE THE PUBLIC HEALTH
STATE AND FEDERAL PARTNERS?
• California Emerging Infections
Program (CEIP)
• California Department of Public
Health (CDPH)
• Centers for Disease Control and
Prevention (CDC)
39
39

40. E. COLI O157 CASE
CONFIRMATION PATHWAY
40
40

41. ENVIRONMENTAL
HEALTH RESPONSE
Jahniah McGill, MPH
Registered Environmental
Health Specialist
Napa County Environmental Health
41

42. HOW DOES ENVIRONMENTAL HEALTH BECOME
AWARE OF FOOD RELATED EVENTS?
Environmental Health
• Reporting Methods
−
−
Online complaint system
Telephone complaint
• Reporters of Illness
−
−
−
Consumer complaints
Food facility operators
Health and Human Services: Public Health
• State & Federal Partners
−
−
−
California Food & Drug Branch (CDPH)
US Food and Drug Administration (FDA)
US Department of Agriculture (USDA)
42
42

43. ENVIRONMENTAL HEALTH
RESPONSE ROLE
Environmental Health Inspectors focus on how the
food became contaminated:
• Receive and interpret foodborne illness complaints
• Investigate suspected food and/or food establishment
− Interview food workers and managers
− Examine food storage, handling, preparation, and
service
− Identify risk factors that resulted in food contamination
− Collect environmental and food samples
− Collect paperwork
43
43

44. ENVIRONMENTAL HEALTH
RESPONSE ROLE
Environmental Health Inspectors focus on how the
food became contaminated:
Implement control measures
• Employee education
• Disposal of contaminated food
• Impound
• Closure of premises
• Administrative hearing process
• Probationary period
44
44

45. ENVIRONMENTAL HEALTH
RESPONSE ROLE
Environmental Health Inspectors refer to the following
agencies:
• CDPH Food and Drug Branch (CDPH)
− Manufacturers, Processors, Wholesale
− Seafood and Shellfish
− Recall of Foods
• CA Department of Food and Agriculture (CDFA)
− All Meat and Dairy Products
• U.S. Food and Drug Administration (FDA)
− Interstate Manufactures, Processors, Wholesale
45
45

46. HOW DO YOU CONTACT
ENVIRONMENTAL HEALTH?
PBES: Environmental Health Division
Main Phone: (707) 253-4471 or (707) 253-4417
Main E-mail: Environmental@countyofnapa.org
County Website:
http://www.countyofnapa.org/PBES/Environmental/
46
46

47. Exercise Ground Rules
 Do not fight the scenario
 Assume the scenario is real and
may impact the jurisdiction and
the participants
 Participate in a collegial
manner: share policies,
plans and practices that
may benefit others
47

48. Exercise Ground Rules
 Be respectful: allow others
to speak and finish their
statements
 Follow communications
etiquette: turn off cell
phones, computers, and
any other electronic data
equipment
48

49. Tabletop Exercise
 The exercise consists of three modules plus an
addendum for planning the November 21, 2013
Functional Exercise
 Each module will identify the key issues followed
by questions for discussion
 Participants are encouraged to share their plans,
policies, strengths and gaps as identified in the
Organizational Self Assessments
49

50. Scenario
On November 18, 2013, healthcare providers at
community health centers, private physician’s offices
and local emergency departments began seeing
previously healthy patients with complaints of
abdominal pain throughout Napa County.
50

51. Scenario (Continued)
Within one day, 40 cases of bloody diarrhea had
been reported by 10 healthcare providers at
community health centers, private physician’s offices
and local emergency departments in the county.
Two days after the first reports of abdominal pain and
bloody diarrhea, 4 patients (of which, 2 are pediatric)
were admitted to the Intensive Care Unit with
symptoms of decreased urine output, lethargy and
persistent bloody diarrhea. These patients were
diagnosed with hemolytic uremic syndrome. Cases
presenting similar symptoms continue to be reported
throughout the county.
51

52. Scenario (Continued)
Five days after the first
reported case, 225 patients
(approximately 10% with
HUS) have been identified
with similar presenting
symptoms at local hospitals,
community health centers
and private physician
practices.
52

53. Scenario (Continued)
Healthcare facility staff has requested guidance
from the local Public Health Laboratory on
appropriate protocols for specimen collection
and laboratory techniques to confirm the
diagnosis.
Healthcare facilities are requesting guidance on
necessary levels of isolation and personal
protective equipment requirements for staff.
53

54. Module 1: Public Health Surveillance
and Epidemiological Investigation
Key Issues:
 Surveillance and epidemiological investigation
coordinated with the healthcare partners
 Implement control measures
54

55. Questions for Discussion
1. When and how would your organization/agency be
made aware of an increase in Shiga Toxin-producing
E. coli isolates within your jurisdiction?
a. Are there multiple modes of communication for this kind of
information?
2. What would prompt an investigation, and who would
undertake the investigation and analysis if an
outbreak were to occur in your jurisdiction?
55

56. Questions for Discussion
3. How does your organization/agency collaborate with
the laboratories?
a. How is testing prioritized?
4. How are control measures issued by Public Health,
Environmental Health, healthcare facilities?
a. How are the control measures implemented by each?
56

57. LUNCH
BREAK
57

58. Module 2: Emergency Public
Information and Communications
Key Issues:
 Alerting and notification of personnel
 Internal and external communications
 Risk communication messaging
58

59. Questions for Discussion
1. What mechanisms and/or technologies are in place
to alert and notify your staff of activation of your
facility’s emergency operations plan?
a. How do you notify staff of activation?
b. Who is responsible to do that?
c.
How often do you test this system?
d. Has this system been used in a real event?
e. Who else do you notify of activation?
f.
How does that occur?
59

60. Questions for Discussion
2. How do you share information with Public Health?
a. What information do you share?
b. What information do you expect from Public Health?
c.
How do you communicate your facility status (and bed
availability) to the local medical health system?
d. How does this information get to the state?
60

61. Questions for Discussion
3. What is your risk communication plan to notify staff,
patients, clients and/or stakeholders of a foodborne
illness outbreak?
a. Who approves the information to be shared?
b. What communication methods are used?
c.
How does your organization participate in a Joint
Information System (JIS)?
d. What would warrant opening a Joint Information Center
(JIC)?
e. How do you manage inquiries from the media,
stakeholders, and the general public?
61

62. Scenario (Continued)
Ambulance companies are reporting an increase in
call volume and extended delays in offloading
patients at local emergency departments.
Hospitals are experiencing continuing surge with
increasing emergency department wait times.
The initial epidemiologic investigation has not
revealed a consistent pattern of age, race,
occupation, geographic distribution or previous
symptomatology among patients which might
indicate a source of the offending agent.
62

63. Module 3: Emergency Operations Center
Management and Medical Surge
Key Issues:
 Response is coordinated through the use of Incident
Command System principles and Command
Centers/Emergency Operations Centers
 Incident Action Plans are developed to guide and
document the response and recovery phases
 Activation of Surge Plans
 Request and/or response to resource requests
63

64. Questions for Discussion
1. How do you plan for an influx of patients including the
access and functional needs population?
a. What types of services can be altered, postponed or relocated to
other sites?
b. Have clinical providers been active in the decision making for
alteration of services?
64

65. Questions for Discussion
2. Which partner organizations can assist in providing
services that you must alter or suspend due to a medical
surge?
a. Do you have Memoranda of Understanding signed with these
partner organizations?
3. How do you request, respond to, distribute, track and/or
return resources in accordance with the California Public
Health and Medical Emergency Operations Manual?
65

66. Resource Requesting
Dr. Karen Smith
Napa County Public Health Officer
66

68. Medical & Public Health Resources
• Personnel
• Services
• Supplies and Equipment
• Transportation
• Facilities
68

69. Healthcare Facility Managers
How to Obtain Resources:
• Communication through accepted local protocols
• Communicating resource arrangements
minimized duplication of efforts
69

70. HC Facility Resource Utilization
• Determine if current resources will meet the anticipated
needs
• Prioritize/conserve what’s available
• Contact suppliers/contractors
• Implement existing agreements
• Request help from the HHSA/DOC - MHOAC
70

72. HHSA Department Operations
Center (DOC)
DOC
Director
PIO
Health
Officer
Safety
Officer
Liaison
Officer
Operations
Section
Planning
Section
Logistics
Section
Finance
Section
Medical
Branch
Health
Branch
72

73. DOC Medical & Health Branch
Operations
Section
Medical
Branch
Health Branch
EMS/Transport
Patient
Tracking
Communicable
Disease
Healthcare
Facilities
Coordination
Laboratory
Alternate Care
Site
Activate
branches as
needed
Mass
Prophylaxis
73

75. CA Mutual Aid System
• CA disaster & Civil Defense Master Mutual Aid
Agreement (MAA)
• Discipline-Specific Mutual Aid Agreements
• Health Care Facilities Mutual Aid or Mutual
Assistance Agreements
75

76. CA Mutual Aid Regions
3
1
2
4
5
6
1
76

77. Regional Disaster Medical & Health
Coordinator/Specialist (RDMC/S)
REOC
Medical Health Branch
RDMHC/S Program
OA EOC
Med. Health Branch
MHOAC Program
OA EOC
Med. Health Branch
MHOAC Program
OA EOC
Med. Health Branch
MHOAC Program
Affected Local Jurisdictions
77

79. Who You Gonna Call?
Public Health/
HHSA!!!
Public Health/HHSA DOC is your
gateway to CA’s mutual aid…
79

80. Tabletop Conclusion
You Survived!
80

81. HOT WASH
81

82. Planning for the November
Functional Exercise
The scenario will be a medical
surge due to foodborne illness.
Customization of the exercise
allows incorporating other
objectives as needed.
Examples include issues
identified in past exercises,
new training or equipment, or
new policies and procedures.
82

83. November Exercise
Issues for Consideration
Exercise Level of Play:
 What level of exercise play do the
organizations/agencies represented today anticipate
for the November 21, 2013 exercise?
 Examples include communications drill, functional and
full scale exercises, level of play may include use of
simulated patients, movement of patients to healthcare
facilities, activation of the joint information center,
provision of mutual aid, etc.
 Will your organization/agency activate its Command
Center/Emergency Operations Center?
83

84. Role of State Agencies
On November 21, 2013, the California Department of
Public Health and the California Emergency Medical
Services Authority will open the Medical and Health
Coordination Center (Formerly the Joint Emergency
Operations Center).
The California Emergency Management Agency is
anticipated to participate by opening the State Operations
Center and the Regional Emergency Operations Centers to
support local and regional exercise play.
This will provide the opportunity for local participants to
request additional resources, submit and receive situation
status reports and respond to California Health Alert
Network (or other notification systems) messages and
receive further direction.
84

85. Evaluations
Please
complete
your
Evaluation…
85

86. Thank You
For Your Participation
Additional materials may be found on:
California Statewide Medical and Health
Training and Exercise Program website:
86