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REPORT
IHR Event Communication Exercise in the WHO Western Pacific Region
.6\ World Health ~---
\'9J Organization Western Pacific Region
WPDSE1206256-ESR
English only
REPORT
r
ERCJSE Cjl.YSTAL
World Health Organization Regional Office for the Western Pacific Manila, Philippines 1-2 December 2011
Not for sale Printed and distributed by: World Health Organization Regional Office for the Western Pacific Manila, Philippines
June 2012
WHOIWPRO tmRA nV MANILA. PHILIPPINES
27 MAR Z013
NOTE The views expressed in this report are those of the participants in the lHR Exercise Crystal and do not necessarily reflect the policies of the World Health Organization.
This report has been prepared by the World Health Organization Regional Office for the Western i?abifi.c:ffdt 1tl'le j:Mtti'cipants of the lliR Exercise Crystal, which was held in Manila; the Philippines fiohi1 to 2 December 2011.
SUMMARY
The International Health Regulations (!HR.) 2005 entered into force in 2007. IHR event conurrunication, such as public health event reporting, consultation, notification, information sharing, verification and determination nf ~ pnhlic health emerge ncy of international concern (PHEIC), are essential components of successful lliR implem entation. The importance of regular lliR communication exercises to strengthen and test the functions of the IHR nationa l focal points (NFPs) and the WHO lliR contact point has been recognized by annual meetings of the Asia Pacific Technical Advisory Group on Emerging Diseases, as well as meetings of NFPs in the Western Pacific Region. To strengthen and maintain the functions of NFPs and the WHO lliR contact point, two IHR exercises (named "IHREx ercise Crystals") were conducted in the Western Pacific Region in 2008 and 2010. In 2009, areal-w orld global public health event, pandemic (HlNl) 2009, occurred. The pandemic response highlighted the vital role of the NFPs and the importa nce of IHR communication to contribute to pandemic risk assessment and situation monitor ing nationally, regionally and globally. The IHR Exercis e Crystal was conduc ted from 1 to 2 Decemb er 2011. It was a modified functional exercis e using a hypothetical scenario to test the assessm ent of a situation utilizing the decision-making instrument contained in Annex 2 of the IHR (2005) and its notification processes. The objectives of the exercise were: (1)
to validate the accessibility of the NFPs and the WHO lliR contact point using register ed contact details; to test NFPs' assessment of public health events using the decision-making instrum ent contained in Annex 2 of the IHR (2005) and its notification process ; and to test the use of teleconference as a means of communication to connect the NFPs at the end of the exercise.
(2)
(3)
All27 NFPs and the WHO IHR contact point in the WHO Wester n Pacific Region were invited to particip ate in the exercise. All NFP contact details (including telephone, fax and e-mail) that are officially register ed in the WHO NFP contact database were tested during the exercise. A total of 18 NFPs (67%) participated in the actual communication s during the exercise . In some Membe r States, it was also supported by WHO country staff members. Teleconferences were conducted at the completion of the exercise on both days. Sixteen Membe r States (89% of participating Membe r States) were able to join the teleconferences. 1n addition to the feedback received during the teleconferences , written evaluation forms were receive d from 13 (72% of participating) Membe r States. Exercise debriefing sessions were conducted to gather feedback from WHO participants. Overall, the exercis e was well-received, and a majority of NFPs could be contact ed using the registered contact details or alternative contact details provide d for the purposes of the exercise. The exercis e found, however, that not all NFP contact details were fully accessible. Short messag e service (SMS) was tried for the fitst time based on the recommendation from the lliR Exercise Crysta12010. Seven NFPs confirmed that they received the SMS, fifteen NFPs used fax communication, and all but one receive d e-mail communication. Nine NFPs were unable to be contacted by telephone.
Despite limited exercise time, most participants were able to facilitate expected communications and information flow, including sharing of information and requests for situation updates from the simulated local public health authorities and the WHO lliR contact point. Half of the participants approved a secure lliR Event Information Site (EIS) posting. Most participants were able to join the teleconferences, with 16 NFPs participating and providing feedback (89% of participants). There were some technical issues with teleconferenc.~ fllc.ilitif':s 11t the WHO Regional Office for the We1:tern Pacific on the first day and issues connecting some Pacific Island Member States on the second day. Feedback from NFPs and Member States was, overall, very positive. The scenario was thought to be realistic and informative. The exercise provided a good opportunity to test lliR communication with WHO, as well as NFP internal communication during an emergency. Participants found that regular lliR communication exercises were useful. On the other hand, there were observations that the time-frames were compressed, and there was not enough exercise time to read and understand the information being provided. To improve IHR communication, the following are the recommendations: (1) Communication facilities for NFPs should be improved. This includes having generic e-mail addresses so that they can always be accessed by any responsible officer and/or duty officer. All responsible staff members should be trained and briefed on relevant lliR communication protocols including practise with EIS postings. Teleconferencing facilities at the Regional Office for the Western Pacific should be updated to ensure that it has the ability to connect multiple Member States in a timely, reliable and clear manner. Regular IHR exercises should be conducted to strengthen and test the functions of NFPs and the WHO IHR contact point. The exercise design should be improved so that an appropriate amount of information is provided in the limited time-frame available for the exercise. Exercise rules must be followed by all participants.
(2)
(3)
(4)
(5)
CONTENTS
1. INTRODUCTION ... ....... ..................... ...... .. ... ... .... ....... ............... ..... ....... .... ... ......................... 1 1.1 Objectives ............................................................................... ... ............ .. ...... ............... 1 1.2 IHR. event communications ..................... ... ........................... ........... ................ ....... ...... ! 1.3 Exercise participants ............................................................... .... ... ..... ...... ... ... .. .. .......... 1 2. PROCEEDINGS ......... ........ ............... ............. ... .. .. ...... ......... ...... .......... ...... .. .. .. ....... ... ... ......... 3 2.1 2.2 2.3 2.4 2.5 Exercise development and scope ................................... ....... .. ... .... ............................... 3 Type of exercise ............................................................ ....... .... .. .................... .......... ..... 3 Roles of exercise participants ......................................................... ...... .... .................... 5 Exercise conduct and participation .. ........... .............................. ..... .......... ..................... 7 Results ............................................................ ......... ..... .. ............. .... ..... .... ..... ..... ...... .. ... 8
3. CONCLUSIONS AND RECOMMENDATIONS ................................................................ 14 3.1 Conclusions ...................... .......... ....... .. ........... ....... ..... .... .. .... ..... .............. ... ................. 14 3.2 Recommendations .......... ........ .. .................... .. ...... ... .... ................... ....... ....... ... .... ..... .. . l5 ANNEXES: ANNEX 1 ANNEX2 ANNEX3 ANNEX4 ANNEX5 ANNEX6 ANNEX? ANNEX8 ANNEX 9 Keywords: Communication I Risk Management I Health personnel-education I Western Pacific Pandemics I Emergencies
PARTICIPANTS' GUIDE EXERCISE SCENARIO AND INJECTS MASTER SEQUENCE: DESIGN AND CONTROL GUIDE FOR SIMULATORS TELECOMMUNICATION SCRIPT PRE-EXERCISE AND CLOSING MESSAGE PARTICIPANTS' BRIEFING EXAMPLE OF NOTIFICATION EXAMPLE OF AN EIS POSTING
1. INTRODUCTION
1.1
Objectives The objectives of the International Health Regulations (IHR) 2005 Exercise Crystal2011
were:
(1)
to validate the accessibility of the National focal points (NFPs) and the World Health Organization lliR contact point using registered contact details; to test NFPs' assessment of public health events using the decision-making instrument contained in Annex 2 of the lliR (2005) and its notification process; and to test the use of teleconference as a means of communication to connect the NFPs at the end of the exercise.
(2)
(3)
1.2
IHR event communications
Ensuring the functions of the designated NFPs and the WHO lliR contact point has been an essential component of the implementation of the lliR (2005) in the Western Pacific Region. Pandemic (HlNl) 2009 was the first public health emergency of international concern (PHEIC) declared in accordance with lliR (2005). This real-world global public health event has clearly demonstrated the value and important roles ofNFPs in facilitating IHR communications, such as timely reporting of the initial H1Nl cases and sharing information through the secure IHR Event Information Site (EIS). IHR communications have proven to be a valuable mechanism to contribute to pandemic risk assessment and situation monitoring nationally, regionally and globally. IHR event communications primarily refer to official communications between Member States and WHO concerning public health event reporting, consultation, notification, verification, information sharing, risk assessment, determination of PHEIC and emergency response under the IHR (2005). They also refer to public health event-related qommunications and information sharing between the NFP and relevant departments and/or agencies within a country or area. 1.3 Exercise participants
Exercise participants included the NFPs in the Western Pacific Region, the WHO Reg;ional Office for the Western Pacific and the relevant WHO country offices. The Member States were divided into two groups. For the first group, the exercise was conducted on 1 December 2011 (09:00-14:00 Manila time), and for the second group, it was conducted on 2 December 2011 (07:00-12:00 Manila time). The exercise schedule for participafmg Member States appears in the Participants' Guide (Annex 1) and in Table 1.
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Table 1. Exercise schedule for participating countries and areas
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2. PROCEEDINGS
2.1
Exercise development and scope
Since the IHR (2005) entered into force in 2007, the importance of regular IHR communication exercises to strengthen and test the functions of the NFPs and the WHO IHR contact point has been recognized by annual meetings of the Asia Pacific Technical Advisory Group on Emerging Diseases, as well as meetings ofNFPs in the Western Pacific Region. At the July 2011 meeting of the Asia Pacific Technical Advisory Group on Emerging Diseases, the Asia Pacific Strategy for Emerging Diseases 2010 workplan was reviewed, and the importance of conducting regional exercises to strengthen NFP response was re-emphasized. To strengthen and maintain the functions ofNFPs and the WHO IHR contact point, two IHR exercises (named "IHR Exercise Crystals") were conducted in the Western Pacific Region in 2008 and 2010. In 2009, a real-world global public health event, pandemic (HlNl) 2009 occurred. This was the first PHEIC declared in accordance with the IHR (2005). The pandemic response highlighted the vital role ofNFPs and the importance of IHR communication to contribute to pandemic risk assessment and situation monitoring nationally, regionally and globally. The IHR Exercise Crystal2008 was limited to verify an outbreak of unknown etiology. The scope of the IHR Exercise Crystal 2010 went beyond the verification process to test and validate other aspects ofiHR event-related communications, including use of the IHR decision-making instrument for making a decision on official notification of a potential PHEIC. It also applied the process of sharing of information through the IHR EIS. 2.2 Type of exercise
The IHR Exercise Crystal2011 was a modified functional exercise, and it used a hypothetical scenario that tested the assessment of a situation, utilizing the decision-making instrument contained in Annex 2 of the IHR (2005) and its notification processes. Only NFP staff members were required to participate in the exercise. The exercise was conducted over a period of 4 hours, equivalent to 2 days in the scenario. Players were asked to engage in real, functional communication with the WHO IHR contact point using the real WHO IHR contact point contact details (llffi@wpro.who.int).
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For the purpose of the exercise, there was a: (1)
Simulated country: The Republic ofCalama nsi communicated to the WHO IHR contact point, via IHK communications. During the exercise, the role of this country was played by the controller. Simulated local public health wzit: The Almond Public Health Unit was a simulated local public health unit within the player's country where the event was occurring. During the exercise, the role of this local public health unit was played by the simulator.
(2)
Virtual, functional communications were conducted with the simulator using contact details (i.e. telephone, fax and e-mail), which were provided in the Participants' Guide. A Simulator s' Guide was also developed, which had additional information about the scenario and would help answer questions posed by players (Annex 4). There was no simulator arranged for other agencies. Players were asked to communic ate with other relevant agencies (e.g. the Ministry of Transport and NFPs in other countries) by recording an action in their Action Log Sheet. Over the time period of the exercise, participants were presented with a number of injects correspon ding to the scenario. Players had to respond to these injects. Due to time constraints, it was recommen ded that players focus on making decisions with the provided scenario informatio n and performing appropriate IHR communications. The injects were: Inject 1.1 Inject 1.2 Inject 2.1 Inject 2.2 Inject 3 Inject 4.1 Inject 4.2 Inject 4.3 -E-mail from the NFP, Republic ofCalama nsi -Media report -E-mail from the director of Almond Public Health Unit - Media report -Situation report 1 - Risk assessmen t report -E-mail from the director of Almond Public Health Unit -Media report
Injects used for the exercise and the master sequence for injects (Annex 3) are attached at the end of this report.
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Figure 1. lHR Exercise Crystal2011: Design and Expected Corrununications
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IHR =International Health Regulations (2005), WHO= World Health Organization. 2.3 2.3.1 Roles of exercise participants Players: NFPs and WHO IHR contact point
Players were expected to carry out event-related corrununications in accordance with their existing communication and operating procedures within the country and WHO. An assessment using the decision-making instrument contained in Annex 2 of the IHR (2005) will be required based on information provided during the exercise. 2.3.2 Exercise management team: Regional Office for the Western Pacific
The role of the exercise management team was to ensure the conduct of the exercise. An exercise management team within WHO Western Pacific Regional Office was established to conduct the exercise. The team consisted of a lead controller, two controllers, several simulators, evaluators and support staff members. The responsibilities were assigned to the exercise team according to their roles.
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Figure 2. lliR Exercise Crystal 2011: Exercise management team structure
'
Exerels~
··
Director {Lead Controller)
Support Staff
Exercise Controller
Exercise Simulator
Exercise Evaluator
Figure 3: The Western Pacific Regional Office team during the lliR Exercise Crystal 2011
2.3.3
Observer and facilitator
WHO country office Emerging Disease Surveillance and Response Unit team leaders or designated staff members acted as observers and/or_ facilitators to support respective NFPs, when requested.
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2.4
Exercise conduct and participation
Al127 NFPs in the WHO Western Pacific Region were invited as exercise players to ·particip-ate irt tlie exercise.· E-mails inviting participants to the exercise were sent out on 11 November 2011. Of the 27 NFPs, 23 (85%) confirmed that they would participate. The exercise participants were divided into two groups. For group one, the exercise was conducted on 1 December, while for group 2 the exercise was conducted on 2 December (Table 1). During the exercise, communication was conducted via short message service (SMS), fax and e-mail with a follow-up telephone call made to all NFPs. All official contact details from the NFP database (as of 30 November 2011) were used and tested for the exercise communications. Prior to and during the exercise, 13 out of 13 (100%) of day 1 NFPs and 12 out of 14 (86%) NFPs provided alternate contact details to be used during the exercise. Exercise participants were provided with the following documents and information: (1)
Pre-exercise material. E-mail invitation to participate in the lliR Exercise Crystal (sent on 11 November 2011); Participants' Guide (sent on 25 November 2011); and a pre-exercise message, reminding exercise participants of important exercise roles and rules of the exercise. Other documents included a PowerPoint briefing, action log, problem log and evaluation forms (sent on 30 November 2011). During the exercise. Exercise injects, including e-mails, situation reports, risk assessment reports and media reports, as well as the teleconference agenda and schedule (Annex 2). Post-exercise material. A post-exercise message was sent to close the exercise (Annex 6).
(2)
(3)
On 1 and 2 December 2011, a total of 18 NFPs (67%) participated in the functional communications during the exercise. On day 1, 12 out of 13 NFPs participated (92%), and on day 2, 6 out of 13 NFPs participated (46% ). Some NFPs were unable to participate due to conflicting or unexpected appointments (3), telecommunications issues (3), a real public health emergency happening at the same time (1) and unknown reasons (2). Figure 4. A national team in a Member State discussing and responding to the exercise scenario during the IHR Exercise Crystal 2011
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In some Member States, WHO country staff members also attended the lliR Exercise Crystal2011. From the Western Pacific Regional Office, first and second-level lliR duty officers of the WHO UIR contact point attended, as well as, the exercise managemen t te:Rm. Within the Western Pacific Regional Office, the Emergency Operation Centre was activated to facilitate the exercise. 2.5 2.5.1 Results Accessibility of the NFPs' contact details
During the exercise, SMS, fax, e-mail and telephone were used to contact the NFPs. Twenty minutes into the exercise, a communication check was conducted. The staff members of the Western Pacific Regional Office used the telephone to call the NFPs using the registered NFP numbers and/or alternative numbers that were provided for the exercise. During this communications check, the receipt of exercise material via SMS, e-mail and fax was checked and recorded. 2.5.1.1 SMS
Based on feedback from last year's exercise, SMS to mobile phones was used for the first time in the lliR 2011 exercise. SMS was sent to all NFPs with registered mobile numbers to announce the start of the exercise. Seven NFPs (26% of all NFPs and 30% of NFPs with mobile numbers registered) confirmed that they received the SMS message. Of the 27 NFPs, four NFPs did not have mobile numbers registered. 2.5.1.2 Fax
Fifteen NFPs (56% of all NFPs and 60% of NFPs with registered fax numbers) confirmed that they received the fax message (inject 1.2). Five fax messages did not go through. Six NFPs were unable to be contacted to check whether they received the fax message. Two NFPs did not have fax numbers registered. 2.5.1.3 E-mail
E-mail was the primary mode of communication with participating NFPs. All but one NFP could be contacted by e-mail. During the exercise, there were 1334 e-mails processed. The number of e-mails sent and received is shown in Table 2. The numbers in brackets indicate number of e-mails excluding internal communication. Table 2. E-mails processed by staff at the Regional Office for the Western Pacific
Day 1 Overall 906 (838) 255 (222)
Day2 428 (391) 144 (125)
Overall 1334(1229) 399 (347)
IHR duty officer Control Simulator
435 (406) 216 (210)
219 (206) 65 (60)
654 (612) 281 (270)
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2.5.1.4
Telephone
Nine NFPs were unable to be contacted using registered NFP details and/or alternative telephone numbers provided. The problems encountered included the following reasons: (1) number being on fax mode; (2) call going directly to voicemail; (3) phone out of service; (4) unanswered; (j) answered but subsequently hung up; and (6) going to a wrong number. Figure 5. Accessibility of national IHR focal point contact details (2010 and 2011)
100% 90% 80% 70% 2.5.
60% 50%
12010 •2011
40% 30% 20% 10% 0%
Fax
Phone
Em a"
SMS
Teleconference
SMS =short messaging system Note: To enabl~_ c.omparison, results are expressed as a percentage of all nationallliR focal points. SMS was used for the first time in the 2011 exercise .
.. 2.5.2 NFP assessment of public health events using the decision-making instrument and its . notification pro~ess Notification
2.5.2.1
During the exercise, 5 out of 18 participating NFPs (28% of participating NFPs) made a PHEIC notification to the WHO IHR contact point. An example of such a notification appears in Annex 8.
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2.5.2.2 EIS Posting During the exercise, 9 out of 18 NFPs (50% of participating NFPs) approved an EIS posting regarding the public health event. An example of an EIS posting appears in Annex 9. 2.5.2.3 Use of teleconference as a means of communication to connect NFPs At the conclusion of the exercise on both days, a teleconference was held between participating NFPs and the Western Pacific Regional Office. The objectives of the teleconference were: (1) to test the use of teleconference facilities as means of communication during a response to a potential PHEIC in the Western Pacific Region, and to conduct a short debriefing and to obtain feedback on the lliR Exercise Crystal 2011.
(2)
Overall, 16 NFPs participated in the teleconferences (56% of all NFPs). On day 1, two simultaneous teleconferences were conducted for the participating Member States in two groups. For group 1, technical difficulties were experienced with the teleconference facilities. On day 1, 12 Member States participated in the teleconference (92% of NFPs for day 1). During day 2, there was some difficulty connecting participants to the teleconference. Only 4 participants (29% of day 2 NFPs and 67% of participating NFPs) were able to be connected to the teleconference. Figure 6: Members of the Division of Health Security and Emergencies at the Western Pacific Regional Office attending the teleconference
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2.5.3
Evaluation and feedback Feedback on the lliR exercise was obtained by: (1) a debrjef after the exercise by teleconference with participating NFPs from Member States and the Regional Office of the Western Pacific debrief sessions; evaluation forms submitted by participants after the exercise; and WHO evaluators and observers. Feedback from the teleconference
(2) (3) 2.5.3.1
After the conclusion of the exercise on both days, a teleconference was held with participating Member States to test the use of teleconference as a means of communication to connect the NFPs at the end of the exercise. During the teleconferences, Member States were asked to provide feedback on the exercise, both positive comments and ways for improving the exercise. The key poiil.ts raised were: (1)
Positive points (a) (b) (c) (d) Communication was informative and rapid. It was a realistic scenario.
The scenario was challenging, and the injects were spaced well. The Participants' Guide was useful. Negative points
(2) (a) (b) (c) (d) (e) 2.5.3.2
There were difficulties in connecting participants to the teleconferences. The telephone line connection was not clear during the teleconferences. There were issues with the telecommunication infrastructure, especially in the Pacific Island countries, which made all forms of communication difficult. On day 1, technical difficulties in teleconferencing facilities at the Western Pacific Regional Office made it difficult to hear other participants . There was a lot of information presented in a limited time-frame, and responses were required quickly.
Evaluation forms
Member States were also asked to fill up evaluation forms attached to the Participants' Guide (Annex 1) and submit them to the exercise management team. Thirteen completed evaluation forms were received from participating Member States.
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1. Did the exercise achieve the exercise objectives? Twelve out of thirteen participants (92%) answered "yes" to this question. The other participants stated that all other objectives were accomplished, but they were unable to connect to the teleconference. Participants found it useful that they were able to test the IHR notification process, the country response to an unusual and/or severe event, and the ability to use teleconferencing. 2. What do you think about the scope of the exercise? Twelve out of thirteen participants (92%) stated that it was "suitable". One participant stated that the scope was "too broad" and that there was "too much information". Participants found that the exercise enabled use of the IHR decision-making instrument, sharing information, and that it covered medical and nonmedical responses to the event.
3. Please rate the usefulness of this exercise to strengthen IHR event-related communication between the NFP and WHO. On a scale from 1 (very poor) to 10 (very good), the average score was 8.5 (range 7-10). Average
t 1 Very Poor
2
3
4
5
6
7
8
9
10
Very Good
4. Did you .find the information presented informative/helpful when working through the scenarios? Twelve out of thirteen participants answered "yes" to the question (92% ). One participant answered "no" and stated that as the scenario names were not in the country language, this made it less realistic. Other comments were that the scenarios and injects were "realistic and plausible", the information was "given in order and sequenced" and that "everything was provided".
5. What are two positive points that you have learned/observed from the exercise? Comments received were:
•
•
•
• •
Information received was complete, timely and comprehensive . It was a reasonable scenario . It was a good opportunity to practise the IHR decision-making instrument . It was a good reminder of the importance of testing communication within the country and outside. It served as a reminder of the Importance of updating local public health units of developments overseas.
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• •
It identified with whom to communicate in an emergency. There is good cooperation between WHO and countries to facilitate sharing of information and posting on the EIS.
n. What nrP Mo negative points that you would suggast for improvcnu:Ttt in thl! future? Comments received were: • • • • There was not enough exercise time. Too much information was received, and time-frames were compressed. There were problems with teleconferencing. The roles of NFPs in preparing EIS postings and the process of information sharing were unclear.
7. Other comments or criticisms Comments received were: • • • 2.5.3.3 It was a very worthwhile exercise. It would be useful if done annually. Having WHO representatives in the country office would be useful during the exercise. Testing of communication tools before the exercise might be useful. Feedback from evaluators
During the exercise, WHO staff members who were assigned as evaluators provided feedback on the exercise based on observations made during the exercise, review of emails, proceedings of teleconferences and debriefing sessions. Key points made were as follows. Overall: There was good participation by Member States, and the exercise provided a good opportunity to test lliR communication. Communication:
•
• • • • •
• • •
•
There were issues with connecting to some countries due to network problems in the participating countries. There were lengthy delays at times, especially for the Pacific Island Member States, in receiving e-mails. Problems occurred when e-mails were sent to the registered address but no one was available (travel or absent), and no backup was provided. There were some telephone numbers that were inaccessible, went to the wrong person or were out of order. Some countries did not have fax machines, or they were not functioning . Some participants had to be contacted via the WHO country office, as initial attempts to contact them had been unsuccessful. Some participants misunderstood the date of the exercise . Some participants did not pick up telephone calls, as it came up as an anonymous number on their phone. There was a time lag in starting the teleconference when connecting all participants . Mobile phone use for the telecoillerence was problematic, as the "mute" button was not used leading to excessive background noise.
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• There were technical issues with the teleconference facility on day 1 in the Western Pacific Regional Office, leading to poor sound quality. Exercise design and conduct:
• Some exercise participants did not use "Exercise Exercise Exercise" or "This is an Exercise" in each message.
• Not all e-mails were copied to the controller. This led to difficulties in monitoring the
• • • •
• •
•
exercise. The exercise time-frame was too short. Some participants did not have time to read and understand all information provided. There was some confusion with the telephone call made to test communication. Some participants thought that it was part of the scenario. Some participants were confused on where "Almond Public Health Unit" (the hypothetical public health unit) was. The process of making an EIS posting was not clear to some participants . The process of using the decision-making tool was not clear for some participants, as it is not used regularly. Some participants did not understand when the exercise ended or were confused that the scenario was real. Some participants were fighting the scenario .
3. CONCLUSIONS AND RECOMMENDATIONS
3.1
Conclusions
Overall, the exercise participants found that the IHR exercise was very useful to test not only communication between the NFPs and WHO, but internal communication processes as well. Under the lliR, the NFP is the national centre designated by the each Member State that should be accessible at all times. During the IHR exercise, 18 Member States participated. However, not all NFPs could be contacted in a timely manner, and some NFPs were unable to be contacted at all. There were delays in the delivery of emails to some Member States, especially the Pacific Island Member States. This was due to Internet issues and other unknown reasons. Some of the telephone and fax numbers registered for NFPs were out of order, incorrect, went to voicemail or were not answered. There were also some difficulties contacting Member States that had registered individual e-mail addresses (instead of a generic e-mail address), especially when the person was on leave, on duty travel or unavailable. Based on feedback from the 2010 exercise, SMS was tried. During the communications check, only 7 NFPs had confirmed that they received the SMS message. Teleconferencing is a useful means of communication to connect participants to discuss issues during an emergency. During the exercise, 12 Member States (92% of participants) joined in the teleconference. Similar to the 2012 exercise, there were difficulties connecting Pacific Island Member States. At the Western Pacific Regional Office, there were technical issues with teleconferencing for group 1 on day 1, which led to a poor-quality connection and difficulties in communicating between participants, due to hearing problems. This has highlighted the need to ensure that teleconferencing facilities at the Western Pacific Regional Office are functioning appropriately for future events.
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The exercise scenario was realistic, informative and generally well-received by participants. However, the amount of information in the injects was at times too much to process in the limited time-frames available during the exercise. In general, participants adhered to the exercise rules, like copying the controller and ensuring that messages indicating that this was an exercise, were stated in the subject and body of emails. However, this was at times inconsistent, which could have potentially led to some confusion. Most participants were able to analyse, discuss the information and take necessary action based on the scenario in a very timely manner. Some NFPs were not clear about the specific actions that were required during the exercise. Five participating NFPs made a notification of a PHEIC, and one-half of the participants approved an EIS posting regarding the public health event presented in the exercise. Overall, participants felt that this was a good exercise and that regular exercises would be valuable to test IHR communications. It is expected that as a result of this exercise, there will be increased awareness about IHR requirements, and there will be an improvemen t of IHR eventrelated communica tions between countries and WHO in the future. 3.2 Recommend ations
3.2.1 Improve communica tion facilities for NFPs The IHR exercise highlighted some of the communication issues faced when accessing NFPs. The NFPs should continue their efforts in improving communication facilities in line with the IHR requirements, so that they are able to be contacted at all times. This includes having a generic e-mail address so that e-mails can be always accessed by a responsible officer if assigned staff members are unavailable (e.g. due to other duties or leave), having a roster system to maintain that NFPs are accessible at all times and regular testing of communication systems to ensure that they are current. 3.2.2 Improve capacity and training for staff members on IHR communication All staff members (NFP and the Western Pacific Regional Office) involved in IHR communication should be regularly briefed and trained on relevant IHR communication protocols to ensure that their skills are up-to-date. This includes practise on EIS postings, especially for Member States that have limited experience in preparing EIS postings. 3.2.3 Improve teleconferen cing facilities The Western Pacific Regional Office should update teleconferencing facilities to ensure that in the event of an emergency, the teleconferencing facility has the capacity to connect multiple Member States in a timely, reliable and clear manner. Member States should have access to teleconferencing facilities in their offices. If mobile phones are to be used, users should ensure that features such as the "mute" function is used to minimize excessive noise during tl).e teleconference. 3.2.4 Conduct regular lliR exercises The importance of regular lliR communica tion exercises to strengthen and test the functions of the NFPs and the WHO IHR contact point has been recognized by annual meetings of the Asia Pacifi.c Technical Advisory Group on Emerging Diseases, which includes the meeting of the NF_Fs in the Western Pacific Region and also during feedback from exercise participants. The exercises should be conducted on a regular (i.e. annual) basis with the involvemen t of all Member States.
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3.2.5 Refine the exercise design The exercise design for future exercises should be improved to ensure that an appropriate amount of information is provided in the limited time-frame available for the exercise. The information and injects should be technically accurate but simple enough to ensure that the right information is provided at the right pace and is not too overwhelming. The exercise rules should be clearly defined and adhered to by participants. This includes copying the control e-mail address in all e-mail communication so that the exercise can be monitored and any issues identified and rectified early, and clearly stating that the message is an exercise message so that there is no confusion whether the message is an exercise message or a real message.
ANNEX 1
1-2 Decem ber 2011
Ensuring the functions of NationallliR Focal Points (NFP) and the WHO IHR Contact Point (CP) has been an essential component of lliR implementation in the Western Pacific Region. IHR event communications primarily refer to official communications between Member Stares and WHO concerning public health event reporting, notification, verification, information sharing, risk assessment, determination of a public health emergency of international concern (PHEIC) and emergency response under IHR (2005). They also refer to public health event related communications between the NFP and relevant departments and agencies within the country. Since lliR (2005) entered into force in 2007, the importance of regular IHR communication exercises to strengthen and test the functions of the NFPs and the WHO lliR Contact Point has been recognized by annual meetings of the Asia Pacific Technical Advisory Group (TAG) on Emerging Diseases, as well as meetings of the NFPs in the Western Pacific Region. At the July 2011 meeting of the TAG, the Asia Pacific Strategy for Emerging Diseases (APSED) 2010 workplan was reviewed and the importance of conducting regional exercises to strengthen NFP response was reemphasized. To strengthen and maintain the functions of NFPs and the WHO IHR CP, two lliR exercises (named "IHR Exercise Crystal") were conducted in the Western Pacific Region in 2008 and 2010. In 2009, a real-world global public health event, pandemic (H1N1) 2009 occurred. This was the first public health emergency of international concern (PHEIC) declared in accordance with the lliR (2005). The pandemic response highlighted the vital role of the NFPs and the importance of IHR communication to contribute to pandemic risk assessment and situation monitoring nationally, regionally and globally. The "lliR Exercise Crystal2011" will be conducted from 1 to 2 December 2011. It is a simple communication and assessment exercise involving NFPs and the WHO IHR CP. Relevant WHO country office staff will support NFPs, as needed. The exercise will last for five hours on day one for each participating NFP. The exercise schedule for participating countries is shown in Table 1.
The objectives of the exercise are to: 1. Validate the accessibility of the Nationa llHR Focal Points and WHO lliR Contact Point using registered contact details;
2. Test Nationa llliR Focal Point's assessment of public health events using the decision instrument contained in Annex 2 of the IHR (2005) and its notification process; and 3. Test the use of teleconference as a means of communication to connect the National IHR Focal Points at the end of the exercise.
The lHR Exercise Crystal 2008 was limited to verify an outbreak of unknown etiology. The scope of the lHR Exercise Crystal2 010 went beyond the verification process to test and validate other aspects of IHR event related commun ications, including use of the lliR decision instrument for making a decision on official notification of a potential PHEIC. It also exercised the process of sharing of informat ion through the IHR Event Informat ion Site (EIS). IHR Exercise Crystal 2011 will be a modified functional exercise, requiring NFP and WHO exercise players to respond to incoming information (e.g. reports) quickly. It will have a new scenario that will test the assessment of the situation utilizing the decision instrument containe d in Annex 2 of lHR (2005) and its notification processes. In principle, only NFP staff are required to participate in the exercise.
All means of communications including e-mail, phone, fax or SMS may be used for IHR communications between NFPs and the WHO lliR CP. Players are expected to act quickly and facilitate smooth commun ications and information flow within the exercise time period, despite the fact that more time may be available in a real world setting (e.g. IHR requires an official notification of a potential PHEIC event to be made with 24 hours of assessment). Every exercise commun ication (written e-mail, fax or SMS and verbal telephone call) should always state "THIS IS AN EXERC ISE MESSA GE" or "EXER CISE EXERC ISE EXERC ISE" at the start and the end of the communication. Every e-mailed exercise communication should always be copied to Exercise Control at Control@wpro.who.int. The exercise may be suspende d and/or ended at any time if it appears that a realworld emergency is occurring during the time period of the exercise.
The exercise will be conducted between 1 and 2 of December 2011. The exercise schedule for participating countries is ~hown below. Table 1. Exercise schedule for participating countries
All NFPs in the WHO Western Pacific Region have been invited to participate in the exercise. Each NFP will participate in the exercise on one day (see Table 1). The exercise will last for 5 hours, including a teleconference at the end of the ~Jt~tds~. The exercise will primarily engage: 1. Duty officer and/or responsible person from each participating NFP. In principle; only NFP staff are required to participate in the exercise. 2. 1st level and 2nd level Duty Officers from the WHO IHR Contact Point for the WHO Western Pacific Region.
WHO Country Office staff (ESR Team Leaders, or other WHO staff as applicable to individual country situations) will observe and, if needed, also facilitate communication between their relevant NFP and the WHO IHR CP during the exercise. At the conclusion of the exercise a Participants teleconference will be held. To enable this, an appropriate telephone number will be requested from participating NFPs (if not previously provided). The purpose of the teleconference is: • • To test the use of teleconference facilities as means of communications during response to an urgent evolving event in the region. To conduct a short debriefing and obtain feedback on IHR Exercise Crystal 2011
Exercise participants include: 1. Players: NFPs and WHO lliR CP Players are expected to carry out event-related communications in accordance with their existing communication/operating procedures within the country and WHO. An assessment using the decision instrument contained in Annex 2 of the International Health Regulations (2005) will be required based on information provided during the exercise. 2. Exercise Management Team: WHO WPRO The role of the Exercise Management Team is to ensure the conduct of the exercise. The Team consists. of:
Controller Provides direction and control of the exercise. Will manage the sequence of events, including setting the scenario and adding injects. Simulator Will play the role of the affected local public health unit. Will also respond to requests from NFP Players regarding event information and updates related to the simulated local public health unit. 3. Observer/Fac ilitator: WHO Country Office ESR team leaders or designated staff WHO Country Office ESR staff will observe the exercise and are highly encouraged to facilitate and assist NFP Players. 4. Evaluator: WHO An Evaluator will observe and evaluate the process and outcomes of the exercise.
All Participants will join the exercise from their normal office (no international travel required).
Exercise play will be over a period of 4 hours, equivalent to 2 days in the scenario. Due to time constraints, Players may not have time for lengthy consultations. Instead, we highly recommend that Players focus on making decisions with the provided scenario information and performing appropriate lliR communications. Real, functional communication to the WHO lliR CP should be done using the real WHO lliR CP contact details (lliR@wpro.who.int). For the purpose of the exercise, there will be a: • Simulated country This "country" will communicate to the WHO lliR CP, via lliR communications. During the exercise, the role of this country will be played by the Controller. Simulated local public health department/unit This will be a simulated local public health department/unit within your country where the event is occurring. During the exercise, the role of this local public health department/unit will be played by the Simulator. Simulated, functional communications with the Simulator can be done via the below details:
•
Please note that there is no simulator arranged for other agencies. If Players want to . conimunicate\vith another relevant agency (e.g. Mimstry of Transportation, NFPs in other countries) they should simply record this pretended 'action' in their Action Log Sheet (e.g. "Called Ministry of Transportation"). This should be done with no real involvement or communication with the agency. Internal discussions within the office of the NFP are encouraged to facilitate game play. All Participants will be required to record their actions taken during the exercise: • Record all actions taken in the Action Log Sheet, including actions taken to communicate with other relevant departments/agencies/individuals (if required based on your communication protocol/procedures) and the results of any assessment made using the lliR decision instrument. Please submit the Action Log Sheet to Exercise Control at the end of the exercise (Control@wpro.who.int). Please always 'close your loop' and send a message to the Exercise Control at Control@wpro.who.int to inform of actions taken by you.
•
Figure 1. lliR Exercise Crystal 2011: Design and Expected Communications
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For problems experienc ed during the exercise: • Record any problems in the Problem Log Sheet. If urgent, contact Exercise Control via e-mail (Control@wpro.who.int) or telephone (+632 528 9035).
Please submit the Problem Log Sheet to Exercise Control at the end of the exercise (Control @wpro. who.int). • Please recognize that this exercise will use a simulated, artificial scenario that may not reflect a real-world situation. Players should accept these artificialities. Please do not be overly concerned by complexities or details associated with the exercise scenario itself. The objective is to work with the scenario to facilitate your actions for communic ations, rather than to challenge it or seek to resolve every last possible detail.
1. Always start and end communication with "THIS IS AN EXERCISE MESSAGE" or
"EXERCISE EXERCISE EXERCISE"
2. Copy every email communic ation to Control@wpro.who.int 3. Do not fight the scenario 4. Close the loop if you have taken your action 5. Do the paper work - log all your activities in the Action Log Sheet 6. Enjoy the exercise!
After the exercise, exercise Players, Observers, Facilitators, Controllers and Simulators will be asked to complete an evaluation form. A debriefing and feedback will also be conducted at the end of the exercise via teleconference. WHO will conduct a post-exercise analysis of accessibility of the NFP contact details and communications related to the event notification process and sharing of information through the IHR Event Information Site (EIS). An exercise Evaluator will also provide their evaluation results. A summary report of the results of 'IHR Exercise Crystal 2011' will be produced and shared with all participating NFPs in the Region.
• • •
The International Health Regulations (2005) Individual country NFP protoc~ls and/or communication mechanisms WPRO interim guide on IHR communication and duty officer system
Action Log Sheet -lliR Crystal Exercise 2011 Name ________ Time/Date Position _ _ _ _ __
Agency _ _ _ _ _ __
Page_of_ Referred to/Resolution
Activity (Call to/Received From; Consultations)
Issue/Information Requested Or Provided
' • Please use this Action Log· Sheet to record details of all non-emailed activities/actions • Please send the completed sheet via e-mail to Control@wpro.who.int or fax to WPRO DSE (+632) 528 9075 immediately after the exercise (by 4 December 201llatest)
Problem Log -IHR Exercise Crystal 2011 Date: _ __ _ __ Exercise Assignment: (circle) Player, Controller, Simul(ltnr, Rvftln::!tnr, Director, Observer Message No. (if known)
Time
Problem
Analysis (Leave Blank)*
• •
Please use this Problem Log Sheet to record any problem encountered during the exercise Please send the completed sheet via e-mail to Control@wpro.who.int or fax to WPRO DSE (+632) 528 9075 immediately after the exercise (by 4 December 2011latest)
IHR Exercise Crystal 20 11 Evaluation Form Please take a few minutes to fill out this form (tick and write down your answers). Your feedback and suggestions will help us prepare and improve future exercises. Thank you for your cooperation! 1. Did the exercise achieve the exercise objectives? (1) Yes (2) No
(3) Not sure
Please briefly explain why? 2. What do you think about the scope of the exercise? (1) Too narrow (2) Suitable
(3) Too broad
Please briefly explain why?
3. Please rate the helpfulness and/or usefulness of this exercise to strengthen lliR event related communications between National lliR Foal Points and WHO:
1 10 Very Poor
2
3
4
5
6
7
8
9
Very Good
4. Did you find the information presented informative/helpful when working through the scenarios? (1) Yes
(2) No
Please briefly explain why?
5. What are two positive points (good things) that you have learned/observed from the exercise? (1) _ _ _ _ _ _ _ _ _ (2) _ _ __ _ _ __ _ _ __
6. What are two negative points (bad things) that you would suggest for improvement in the future? (1) _ _ _ _ _ _ _ _ _ (2) _ _ _ _ __ _ __ __ _
7. Please add any other comments or criticisms:
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Figure 1: IHR Exercise Crystal 2011 Design and Expected Communications
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- IHR Ex~rcise C~ntrol (Controller)
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INJECTS
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(Please do not distribute these contact details to non-exercise participants) List of National lliR Focal Points in the Western Pacific Region (As of 29 November 2011)
Contact Details of Exercise Participants
WHO Country Offices and Team Leaders of the Emerging Disease Surveillance and Response Unit
Dr Babatunde Olowokure
Epidemiologist
IHR Exercise Crystal2011: Role Matrix ofDS E/WP RO Staff 1 - 2 December 2011 28 Novem ber 2011 (Draft )
1s line IHR Duty Officer 2 line lliR Duty Officer 3 line lliR Duty Officer Simula tor 1 (S1) Simula tor 2 (S2) Simula tor 3 (S3) Evalua tor Observ er Contro ller 1 Contro ller 2 Lead Contro ller
Dr Ruth Foxwe ll Dr Taman o Matsui Dr Chin-K ei Lee Dr Jeff Partrid ge & Mr Thoma s Cotter Dr Koji Nabae & Ms Satoko Ms Joy Carninade & Mr Piers Mook Dr Satoko Otsu Dr Charun i Senana yake & Ms Sara Stone Dr Ranil Appuh amy Ms Qiu Yi Khut DrLiA ilan
Dr Ruth Foxwe ll Dr Taman o Matsui Dr Chin-K ei Lee Dr Jeff Partrid ge &
Mr Thoma s Cotter Dr Koji Nabae & Ms Satoko Ms Joy Camin ade & Mr Piers Mook Dr Satoko Otsu Dr Charun i Senana yake & Ms Sara Stone Dr Rani! Appuh amy Ms Qiu Yi Khut DrLi Ailan
PROP OSED MEMBER STAT E GROU PING FOR DAY 1
PROP OSED MEM BER STAT E GROU PING FOR DAY 2
ANNEX2
EXERCISE SCENARIO AND INJECTS Overview of the Scenario The scenario is based around an outbreak of an unknown disease in the Orange district of the Republic of Calumo.nsi and subsequently an outbreak in the pruticipatlug NFPs wuutry. A disease outbreak in the Republic of Calamansi affects 25 people with 3 deaths. Cases present with respiratory symptoms with progression to neurological symptoms. Cases are clustered around a group of road workers. There are a number of delegates from the Republic of Calamansi attending a Road conference in "Almond" district in each of the NFP's country. Therefore, the republic of Calamansi shares· this information with the WHO IHR Contact Point (Inject 1.1 ), who then shares it with the NFPs. A newspaper article in Calamansi reports this event (Inject 1.2). The Almond public health unit reports a cluster of respiratory illness which is initially thought to be influenza. Initially, all cases are stable but testing had been negative including a negative result for influenza point of care test. The NFP was informed as it involved a number of international delegates. (Inject 2.1). It is not known initially whether the delegates are from Calamansi or not. Soon after, a local newspaper reports this cluster of illness. It also states that there are reports of the illness being severe. (Inject 2.2) The Almond .PHU sends its first situation report to the NFP outlining the current situation (Inject 3).The first 3 cases that were admitted had deteriorated with all of them developing neurological symptoms. One person has died. It is also found that all 3 cases are from Calamansi. A further 13 delegates had presented to the hospital with respiratory symptoms. Of these, 2 had deteriorated developing neurological symptoms. As initial testing at the hospital had been negative, serum samples and nasopharyngeal swabs were sent to the national laboratory for further testing. The Almond PHU also request for more information about the Calamansi outbreak from the NFP. With the assistance from the National government, a risk assessment team is formed to perform a risk assessment. The risk assessment report (Inject 4.1) is sent to the NFP. The risk assessment report states that the causative organism is unknown and the disease is more severe than expected, the likelihood of the disease spreading in Almond district or internationally is low and that the magnitude of impact on public health if it occurs is low. The report concluded that the overall risk is minor to moderate. An additional inject (Inject 4.2) reports information from the hotel manager that two ill delegates had left for their home countries. This was supplemented by a media report. (Inject 4.3) Inject 1.2 Inject 1.2 Inject 2.1 Inject 2.2 Inject 3 Inject 4.1 lnject4.2 -Email from NFP, Republic of Calamansi - Media report - Email from Director of Almond PHU - Media report - Situation report 1 - Risk assessment report - Media report
Figure 1. Exercise design and expected actions:
IHRDD:·
INJECT 1.1
Date: Dec 01, 2011, 0900 Dear WHO IHR Duty Officer The NationallliR Focal Point of the Republic of Calamansi wishes to advise you of a cluster of illness of unknown origin affecting 25 people in Orange District and causing 3 deaths. The town of Orange is located 35 kilometres south of Calamansi Capital City, along the Luzoku Highway (the main highway connecting North and South Calamansi). The population of the district is 45,500 people and it is mainly a farming community. The district is serviced by one rural hospital. On 20 November 2011, a labourer working on a road project in the district presented to Orange Rural Hospital with sudden onset of high fever (40°C), myalgia, cough and coryzal symptoms. Influenza was suspected and he was treated with antivirals and intravenous fluids. 1 day after the onset of symptoms he developed neurological symptoms. He died 72 hours after the illness onset. A rapid diagnostic test for influenza was negative. From 21-25 November, a further 24 cases who were also working on the same road project, presented to Orange Rural Hospital with similar symptoms. Of these another 2 have died, bringing the total number of cases to 25, with 3 deaths The main symptoms of the disease are similar to an influenza-like illness. 38% of presenting cases subsequently developed neurological disease and progressive deterioration of neurological function, leading to seizures, coma and in some cases death. The Infectious Disease Unit, Ministry of Health of the Republic of Calamansi has sent a Rapi~ Response Team to Orange, to supplement staff at Orange Public health Unit to assist with the outbreak investigation. The team consists of an infectious disease specialist, an epidemiologist, a laboratory specialist and 2 support staff. The MOH has also sent medical supplies to Orange, including personal protective equipment (PPE) and medication. Laboratory samples including serum and sputum samples have been sent to the National reference laboratory for further investigation. It is not known at this stage if the outbreak has spread further than Orange District. Enhanced surveillance has already been implemented in the neighbouring districts. We understand that a team of government officials from the Department of Highways, Orange District, are currently attending an international conference in [name of country], in the resort town of Almpnd. It is not known whether these officials have had contact with any cases. We are attempting to contact them. The Calamansi lliR NFP will keep you informed of any additional information. Kind regards, Dr Citrus Pomelo NationallliR Focal Point, Ministry of Health, Republic of Calamansi Control @wpro.who.int Telephone: (+632 528 9035). THIS IS AN EXERCISE :MESSAGE
INJECT 1.2
INJECT 2.1
THIS IS AN EXERCISE MESSAGE Date December 1, 2011,0930 Dear Colleagues, This is to inform you of a cluster of respiratory illness among international delegates attending a workshop at the Lemonia Hotel in the Almond district. Three international delegates attending the workshop presented with a sudden onset of high fever and Influenza like symptoms to the Almond District Hospital on 30 November 2011. The regional workshop titled "Improving bitumen characteristics in roads in tropical regions" commenced on 28 November 2011, and is attended by participants from Ministries of Road of Member states in the region. There are 30 participants in total. All three cases are treated in a single room and have been treated with antivirals. They are receiving Oxygen therapy via nasal prongs and their observations have been stable. Hospital staff are practising appropriate respiratory infection control procedures. None of the participants have had contact with sick poultry and Avian Influenza is not suspected. Blood results (taken at admission) for all three cases have shown no major abnormalities besides a mild eosinophilia. X-Rays of these cases have shown a diffuse mild interstitial pattern with no focal areas of consolidation. We have sent naso-pharyngeal swabs and serum samples to the National Diagnostic Laboratory for testing and the results are expected in a few days time. The clinical condition of the admitted patients is currently stable. We have advised the workshop organiser to be on the lookout for further cases and ask them to report to the hospital if they develop influenza like symptoms. We have given them fact sheets on influenza to be distributed to all participants. We continue to monitor the situation but please feel free to contact me if you have any questions regarding the report. Kind regards Dr Altum Febris. Director,
+. . . . . . . . . . . .. TillS IS AN EXERCISE MESSAGE
Telephone +(632) 528 9650 Email: Simulator@wpro.who.int
INJECT 2.2
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INJECT 3 THIS IS AN EXERCISE MESSAGE Date: 01 December, 2011; 18:20 Dear Colleagues, I had previously informed you of a cluster of respiratory illness among delegates attending an international conference at the Lemonia Hotel in Almond district. I am writing to you to provide an update of the situation. Attached please find the situation report. I also understand that there is a similar outbreak in the Republic of Calamansi. We would be grateful if you let us know if there is any further information of the outbreak in that country. Kind regards Dr Altum Febris. Director
Telephone +(632) 528 9650 Email: Simulator@wpro.who.int
+
Almond Public Health Vnlt
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THIS IS AN EXERCISE MESSAGE
* ************ **********
All'll.o:nd Public Health Unit (Telephone: +(63l} 528 9650 I Email: srmulator@wpro.who.int
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SITUATION REPORT #1 December 1, 2011, 18:00
Summary • • • • 1 death 4 cases in Intensive Care Unit (ICU) 11 cases admitted with respiratory symptoms. Currently stable 44 delegates and hotel staff are quarantined at the hotel
Background A 3 day international workshop titled "Improving bitumen characteristics in roads in tropical regions" sponsored by the Department of Roads has been taking place in Lemonia Hotel, Almond District, since 28 November 2011. A total of 30 delegates are attending this conference. There are 30 staff working at the hotel.
Clinical Summary On 30 November 2011, 3 international delegates (Calamansi nationals) attending the workshop presented to Almond District Hospital with a sudden onset of high fever and influenza-like symptoms.
The initial diagnosis was influenza. All three cases (age 35, 54 and 44 years) were isolated together in a single room and treated with anitivirals. Six to 12 hours after admission the clinical conditio n of all three patients deteriorated. Case 1: 35 year old male. Presented with cough, coryza, fever (39.4°C), myalgia and headache. Onset of symptoms was 29 Nov ember 2011. Six hours after presentation, progressive reduction in level of consciousness, He became unrespnnsivf': to voice, pain or other stimuli and oub:wqucntly develope d focal seizures. He died 12 hours after admission. Case2 54 year old male. Case 1 and 2 shared the same hotel room. Presented with cough and fever (40°C) and headache. Date of onset of symptoms - 29 November 2011. 24 hours after admissio n, developed nausea, dizziness and confusion. Developed grand-mal seizures and was treated with anticonvulsants. He is currently in a serious but stable condition in ICU. Case 3: 44 year old female. Presented with runny nose, headache and fever (38.4°C). Date of onset of symptoms 28 November 2011. 12 hours after admission, developed nausea and vomiting . She developed mild confusion. She is currently in a serious but stable condition in ICU. Blood results for all3 cases show mild eosinophilia, but no other major abnormalities. Normal leucocytes. X-rays show a diffuse mild interstitial pattern with no focal areas of consolid ation. Rapid point-of-care testing for influenza in these three cases has been negative. Naso-ph aryngeal swabs and serum samples have been sent to the National Diagnostic Laboratory for repeat testing and additional testing for viruses including Japanese Encephalitis, Dengue, Herpes Simplex Virus, Nipah virus and other entero and arboviruses. No post-mortem facilities are available at the hospital. 13 other delegates from the conference presented to Almond District Hospital yesterday with respiratory symptoms and were admitted for observation and treatment. Two subsequently developed neurological symptoms and have been transferred to ICU where they remain in a stable condition. The other 11 delegates are being closely monitored and remain in a stable conditio n. Initial testing done at the hospital laboratory have not shown anything significant. Laborato ry specimens including nasopharyngeal swabs and serum samples have been sent to the Nationa l Diagnostic Laboratory and are processed as a priority. We are awaiting results.
Public Health Actions Hospital management • Hospital staff had practised appropriate respiratory infection control procedures and are continuing to do so. There are no reports of illness from hospital staff. • All other delegates and hotel staff involved in the workshop (number =44) have been quarantined at the hotel. No report of illness so far in these people. Education • A health alert advising residents of Almond district to be aware of respiratory symptom s and present early to hospital has been prepared. This will be published tomorrow in the daily newspaper, .The Almond Bulletin, and will also be broadcast on local radio. Enhance d Surveillance • Public health units in neighbouring districts have been advised to monitor reports of respiratory illness and to report any unusual activity. PHUs are working with the local hospitals and sentinel surveillance medical clinics to monitor disease reports and potentia l outbreaks.
Other information • We have deployed a response team including an infectious disease specialist, nursing staff and an epidemiologist to assist with this outbreak investigation. • A risk assessment team consisting of a senior surveillance officer and an epidemiologist (member of the response team) from the Almond PHU; with assistance from a Public Health Medical Officer (with infectious disease expertise) and a risk communications expert from the capital city will be conducting a risk assessment. We will forward the findings when available.
THIS IS AN EXERCISE MESSAGE
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INJECT 4.1
THIS IS AN EXERCISE MESSAGE Date: 2 December 2011, 11:10 Dear Colleagues, You would previously have received a situation report regarding the respiratory disease outbreak at Almond Hospital. The Almond Public Health Unit (PHU) risk assessment team has conducted a risk assessment on this outbreak to determine the risk of further spread of this disease.
The likelihood of the disease spreading in Almond district or internationall y at this point in time is low because: • The event, at this point in time remains localized; • There are appropriate public health interventions in place to prevent further spread. The magnitude of the impact on public health if the event were to occur will be moderate because: • The causative organism is unknown at this stage and the evolution of cases is more severe than is expected; • Transmissibility of this organism is unknown but appears to require close contact for transmission; • The case fatality is low; • Enhanced surveillance is in place in Almond and neighbouring districts; • Health care capacity is good in the Almond District. The overall risk is therefore minor to moderate Recommende d actions: • Continue clinical management of cases with particular attention to detecting and managing neurological complications. • Follow up results of laboratory testing from the National Diagnostic Laboratory. • Continue enhanced surveillance in Almond District as well as neighbouring districts. • Continue quarantine and other public health measures to minimise spread of disease. A detailed risk assessment report is attached. Kind regards Dr Altum Febris. Director
Telephone +(632) 528 9650 Email: Simulator@wpro.who.int
TIDS IS AN EXERCISE :MESSAGE
THIS IS AN EXERCISE :MESSAGE
Alft'lond Public Health Unit (Telephone: +{632} !>28 96SQ I Email: Simulator@wpro.who.rnt-1
RISK ASSESSMENT REPORT Date: 2 December 2011, 11:00 Objectives • To assess the public health risk of the current outbreak spreading further. Background
Current event • On 30 November 2011, 3 delegates attending an international workshop at Hotel Lemonia at the resort town of Almond presented to Almond Hospital with an Influenza-Like lllness (ILl). Age range 21-54 years. All3 cases were treated with Oseltamivir and supportive therapy. Despite initial improvement, their clinical condition deteriorated after 12-24 hours of admission. All 3 cases developed severe neurological symptoms with progressive loss of neurological function. One case died and the other 2 cases are in a serious condition in the Intensive Care Unit (source: Almond PHU Sit rep #1, Dec 1). • Twelve hours after the initial 3 cases presented to Almond hospital, 13 other workshop participants presented to the same hospital with symptoms of an ILl (cough, fever, runny nose). All cases were admitted and treated with Oseltarnivir and supportive therapy. Their presenting symptoms were generally mild, but 2 cases subsequently developed neurological symptoms and were transferred to the ICU. They are in a stable condition. Of these 13 patients, 11 others are being monitored closely (source: Almond PHU Sit rep #1, Dec 1). • Of the 16 patients, three are Calamansi nationals. Two of these Calamansi patients shared a room at the hotel. There are two other delegates attending the workshop from Calamansi who remain asymptomatic (source: Almond PHU Sit rep #1, Dec 1). • futerviews of the 13 patients (who presented with symptoms 12 hours after the initial cases presented) have found that 10 of them reside at the sanie wing of the hotel. The 3 other cases had spent a lot of time with one of the ill Calamansi cases at a function after the conference (from Almond PHU Sit rep #1, Dec 1). • Case Fatality Ratio- 6% (1 out of 16 cases); fucubation period (based on 13 cases)- 12-24 hrs; Progression to neurological disease- 25% (4 out of 16 cases)- (source: Almond PHU Sit rep #1, Dec 1). • Preliminary laboratory testing has failed to identify a cause of their illness. Rapid Point of Care testing for influenza has been negative (source: Interview with Dr Rind, Chief Laboratory technician, Almond Hospital, Dec 2). • All delegates arrived at Lemonia hotel on 25 November 2011 (source: Interview with Hotel Manager, Lemonia hotel, 2 December 2011). Other information • An outbreak of a disease with similar symptoms has been reported in the media (source: Calamansi News, November 29). The Director of the Almond PHU has requested more information about his outbreak.
Action already taken • All other participants and all hotel staff are currently quarantined at the hotel. There have been no reports of illness so far among those who were quarantined (source: interview with Dr Febris, 2 Dec 2011). • All quarantined participants and hotel staff have been fully cooperative (source: Observation and interview with Dr Febris, 2 Dec 2011). • Laboratory testing of nasopharyngea l swabs and serum samples on all cases has been undertaken. Additional samples have been sent to the National Diagnostic Laboratory for repeat testing and testing for other viruses (source: review of case notes from Almond hospital and interview with Dr Febris, 2 Dec 2011). • Enhanced surveillance has been implemented in surrounding districts and no reports of increased ILl or outbreaks have been reported (source: Surveillance reports and information from interviews from surrounding public health units). • Media messages have been sent to the public to advise them of precautions and to present early to the hospital if symptomatic (source: interview with Dr Febris, 2 Dec, 2011). Risk questions to be answered: What is the risk that • the current outbreak will affect residents of Almond? • the outbreak will spread overseas? Hazard assessment: • Hazard: Unknown respiratory pathogen or a potentially novel organism. • Is it lab confirmed? Current laboratory investigations are inconclusive. Blood culture results (Aerobic and anaerobic) are negative after 48 hours of growth. Specimens (serum and swabs) have been sent to the National Diagnostic Laboratory and are awaiting results. Preliminary testing for influenza (PCR) has been negative and no organism has been isolated (source: Interview with Dr Rind, Chief Laboratory technician, Almond Hospital, Dec 2). • Disease presentation and pathogenesis: Current available information from the Almond hospital states that there are 16 cases, 1 death, 4 in ICU. Presentation is primarily with influenza-like symptoms. Twenty five percent of cases (4 out of 16 cases) have progressed to severe neurological symptoms, requiring care at the ICU (source: review of case notes, Almond hospital, 2 Dec 2011). • Susceptibility and risk factors for the disease is not known. All case are adults (source: review of case notes from Almond Hospital, 2 Dec 2011). • Background on Neurological complication with influenza: Involvement of the Central Nervous System (CNS) in influenza virus infections is not common'. Influenza-related neurological complications (INC) occur more commonly in children. 2 Many cases have underlying co-morbidities. During the pandemic H1N1 2009, rates of INC of up to 8% have been reported in hospitalized children. 3· 1. Steninger C, Popw-Kraupp T, Laferi H et al: Acute encephalopathy associated with Influenza A virus infection Clinical Infectious Diseases 2003;36: 567-574 2. Fraaaij P and Heikkinen T: Seasonal influenza: The burden of disease in children. Vaccine 2011; 29: 7524-7528 . 3. Frobert E, Sarret C, Billaud G et al: Pediatric neurological complications associated with the A (H1Nl)pdm09 influenza infection. Journal of Clinical Virology 2011; 52: 307-313
Conclusion: The disease outbreak is caused by a potentially unknown organism, or an unusual strain of influenza. The organism is yet to be identified. Patients are presenting with unexpected symptoms. They are presenting with features similar to influenza and 25% progress to develop neurological symptoms. --
Exposure assessment: • All cases have had very close contact with each other. The secondary cases stayed in the same hotel wing and/or have had close contact. There is no known contact with poultry or other animals (source: review of Almond hospital case notes and interview with hotel management and interview with Dr Febris 2, Dec 2011). • There is no evidence that the infection has spread to other delegates despite the delegates spending time together in a large air conditioned conference .hall and having several small group activities (source: interview with Dr Febris, 2 Dec 2011). • None of the hotel staff, including staff who had been involved in cleaning the hotel room of the index case have reported any illness (source: interview with Dr Febris, 2 Dec 2011). • All delegates and hotel staff have been quarantined at the hotel. As the, conference is being held at the hotel and is fully catered, there has not been staff or guest movement outside the hotel (source: interview with hotel management and Dr Febris, 2 Dec 2011).
Conclusion: Appears to be respiratory spread, however, the transmissibility of the disease appears to be low. Vulnerability assessment: • Health care capacity in the Almond District is good. A support team has been sent from the country capital to assist in the response. • Laboratory capacity in Almond District is limited. Samples need to be sent to the National Diagnostic Laboratory for further/confirmatory testing (source: Interview with Dr Rind, Chief Laboratory technician, Almond Hospital, Dec 2).
Conclusion: Good health care system in Almond District and surrounding districts. Increased surveillance that has been implemented is expected to pick up unusual or unexpected disease activity. Overall level of Risk This outbreak is potentially caused by an unknown organism or an unusual strain of influenza. The evolution of cases is more severe than expected for influenza. · The likelihood that the disease will spread in Almond District, neighboring districts or internationally is UNLIKELY. The magnitude of the impact on public health if this were to occur is MODERATE because the case fatality is low. Although the rate of neurological complications is higher, the patients make a good recovery. Therefore the Overall level of risk to residents of Almond District or internationally is MinorModerate. Note: This risk assessment has been conducted using a wide variety of sources and the best evidence available as of 2 Dec 2011. As laboratory results are still pending and epidemiological and clinical data is preliminary, it is expected that the risk level may change. A new risk assessment will be conducted once the laboratory results are confirmed and/or if there is a significant change in case numbers or seve~ity.
Recommendations for action: • Continue clinical management of cases with particular attention to detecting and managing neurological complications. • Follow up results of laboratory testing from the National Diagnostic Laboratory. • Continue enhanced surveillance in Almond District as well as neighbouring districts. • Follow up information from the Republic of Calamansi about their outbreak investigation. • Continue quarantine and other public health measures to minimise spread of disease.
THIS IS AN EXERCISE MESSAGE
INJECT 4.2
THIS IS AN EXERCISE MESSAGE Date: December 2, 2011; 15:45 Dear Colleagues, I am writing to provide you with an update of the situation in _ Almond district. We have just been informed by the manager of Lemonia hotel that two of the international delegates who were under quarantine had left the hotel without permission. The manager of the hotel has advised us that the delegates who left had complained of a fever and had stated that they would like to go back to their home country for treatment. We are attempting to contact these two individuals using contact details that were registered, but we have so far been unsuccessful. This information is provided for your necessary action. Kind regards Dr Altum Febris Director
Telephone +(632) 528 9650 Email: Simulator@wpro. who.int
THIS IS AN EXERCISE MESSAGE
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Invitation for Teleconference
THIS IS AN EXERCISE MESSAGE Dear Colleagues, We would like to invite you to a teleconference between the National IHR Focal Points and WHO WPRO from 13:00 to 14:00 Manila time, 1 December 2011.
If you have not previously provided us with a teleconference number, please do so immediately. Please find the proposed agenda attached. Kind regards WHOWPR O
******* ******* ******* ** IHR Exercise Crystal 2011 Proposed Teleconfere nce between WHO WPRO and NFPs Date: December 01, 2011 Time: 13:00 to 14:00 (Manila Time) Participant s: • Participating NFPs • WPRO/DSE Objectives: 1. To test the use of teleconference facilities as means of communications during response to a potential PHEIC in the Western Pacific region. 2. · To conduct a short debriefing and obtain feedback on the IHR Exercise Crystal 2011 Proposed Agenda • Welcome and opening remarks (WHO/WPRO) • Self introduction (all participants) • Use of teleconference facilities during an emergency (WHO/WPRO) • NFP feedback regarding the 2011 IHR Exercise Crystal (NFPs) • Positive aspects • Suggestions for improvement • Closing remarks (WHO/WPRO) THIS IS AN EXERCISE lVIESSAGE
MASTE R SEQUENCE Design & Control
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WPRO Exercise Team
ANNEX4
GUIDE FOR SIMULATORS (PHU) Introduction Welcome to the lliR Exercise Crystal, 2011 ! The participants guide provides information about the exercise including the objective, course and rules of the exerci se. This document will provide additional information for the simulators to assist them during the exercise. The simulator will play the role of a Public Health Unit (PHU) called "Almond Public Health Unit", located in "Almond District". The Director of the Public Health Unit is "Dr Altum Febris". Please remember" Do not fight the scenarios". Be creative to provide requested information to facilitate exercise communications. Please feel free to create side stories as needed based on the main scenario. Feel free to adapt your response for the pacific context on day 2. Overview of the scenario There is an outbreak of unknown aetiology in a hypothetical countr y called "The Republic of Calamansi". The Ministry of Health of this country advises the lliR Duty Officer of this outbreak and also says that a few citizens of this country from the affecte d area are attending the conference in the participating player's country, although it is not known whether they are exposed or not. (Inject 1.1). This is supplemented by a media report (Inject 1.2) The Almon d public health unit provides a situation report to the NFPs that there are 3 residents admitted to Almon d hospital but all are stable (Inject 2.1) . A media report follows shortly thereafter (Inject 2.2) suggesting that at least one case is in a serious condition. The Almon d public health conducts an investigation with assista nce from the Minsitry of Health. They produ ce a situation report (Inject 3) and subsequently a risk assessment report (Inject 4). These reports are sent to the NFP. These reports should promp t the NFP to make an official notific ation and subsequently, an EIS posting of a potential Public Health Event of International Conce rn (PHEIC). Overview of the Exercise The exercise can be divided into three phases. In the first phase, the focus is on c.ommunication between the various players and simulators. In the second phase, the scenario is further developed by adding a situation report and a risk assessment to prompt NFPs to think about making a notification to the WHO about a potential PHEIC . The third phase is about providing a notification and an EIS posting. At the conclusion of the exercise, there will be a teleconference. 0900-0940 (First stage) See Inject 1.1 and 2.1 and the media reports 1.2 and 2.2 Additional details and response to possible questions are provid ed below . ..
:
Background • •
• •
• •
•
Almond Public Health Unit is a small public health unit located in the Almond district. . It has some core epidemiology staff, but for this outhreak, this PHU unit has been supplemented with staff from the capital city, in particular for the risk assessment. The Almond district's population is 50,000. It has several resorts and a picturesque 8UuuuuJiug. (mountains or water depending on country!) It is a very popular town for international meetings. The most common venue for the meetings is Lemonia hotel. Lemonia hotel is a small hotel with 30 full time staff. It is isolated from the rest of the main town and it is widely promoted as an eco resort. The hotel has limited staff movement to the Almond town centre except for supplies. The hotel has its own supply chain and it actually grows many of the produce at the grounds of the hotel. (this reduces the risk of disease spread outside the hotel). There are no animals or opportunities for contact with animals at the hotel grounds.
Clinical manifestations and public health measures: • • • • • • • • • • • The three hospitalized cases are international delegates attending the workshop. In the initial stages of the scenario, all 3 delegates are stable. They have been treated with anti-virals and Oxygen therapy. They have all been isolated in a single room and the staff looking after them are practising appropriate infection control procedures. They are showing good clinical improvement. At this stage YOU DO NOT KNOW whether these delegates are from the Republic of Calamansi or not. Your team is interviewing hospital staff to get this information. There are a total of 30 delegates attending this workshop from different countries. There are 5 participants from the Republic of Calamansi. All the hospitalized cases had high fever (>39 degrees Celsius). Other common systems are coughing, profuse sweating, headaches, joint pain, difficulty in breathing. Blood results are not abnormal, besides a mild Eosinophilia. Neutrophils are normal. Blood culture results are still pending. Rapid Point of Care testing for influenza for all three patients have been negative. Samples have been sent to the national lab for further testing. X-Rays have not shown focal areas of consolidation. There is diffuse mild interstitial shadowing consistent with a viral pneumonia. Public Health Control Measures that have been implemented are: All staff practising respiratory infection control procedures; Hotel staff alerted to inform residents to present early if they show signs of illness; and Strict isolation is in place for the 3 cases. A media report reporting that there are sick cases will be sent to the players. This may prompt further questions from the players. If further questions are requested you may wish to say that a situation report is being prepared and will be sent to them as soon as possible. Additional information that may be used in the interim are: That you have heard that one patient is in critical condition and has been transferred to the Intensive Care Unit (ICU); The two other delegates are also showing some deterioration but this has not been confirmed; There are unconfirmed reports that a number of delegates have presented to the hospital, but no numbers are currently available; and You are working closely with the hospital authorities to get more information.
•
• •
0940-1015 (Second stage) During this stage the players receive more informatio n abou t the evolving outbr eak in Almond district involving delegates attending the workshop in Lemo nia Hotel. Situation Report 1 Th~ pl;'lyers would have received sltua tionr evull l. This is the situation report prepa red by the Almond Public Healt h Unit in conjunction with the epidemiologists sent from the capital city.
Ther e is also a request from the PHU for additional information from the Republic of Calamansi as it is thought to be a very similar outbreak. Please read Situation report 1 (fuject 3) Additional information: Clinical fuformation • 2 cases in the ICU are stabl e. Neurological funct ions are slowly improving. They are being monitored closely. Both of them are receiv ing anticonvulsant treatment. • Lab results at the Almond hospital are inconclusiv e. • Serum samples have been sent to the National Diagn ostic Laboratory for further testing (as per situation report). It will take 1 to 2 days for the results to be available. • Beca use it is a small hospital, no post mort em facili ties are available. Hospital proto col does not allow transfer of the body to anoth er facility for post mortem when there is an infectious disease transmission risk. • The 13 other delegates who presented have simil ar symptoms to the 3 index cases, however, the presentation is variable in intensity. • As with the 3 index cases, laboratory testing is incon clusive and their samples have been sent to the National lab for further testing. • Two of them showed similar neurological deter ioration and have been transferred to the ICU. • No specific risk factors for severity of illness have been identified. Patients who developed neurological disease have been healthy or have only mino r chronic diseases (for example mild hypertension). • Thes e two cases are not Calamansi nationals. • Ther e are other Calamansi nationals attending the workshop but they are not ill. Other information: • • • • • 44 other delegates and hotel staff have been quarantined . Every one has cooperated with quarantine measures as they are fearful that they woul d get the disease. None of the international delegates have requested that th'ey go back to their own countries. None of the 30 staff members at the hotel are show ing symptoms Most of the hotel staff live in the hotel for extended periods of time and there is limit ed movemerit in and out of the hotel. One famil y has been conta cted and has been quarantined. The Publi c Health Units have been alerted to the outbr eak and are implanting enhanced surveillance measures. No unusual activi ty has so far been reported.
•
Risk Assessment Report The key messages in this risk assessment report are: 1. The disease seems novel. The severe neurological side effects are unexpected. No organism has been isolated. 2. The likelihood that the disease will spread to other residents in the district and to other districts internationally, is LOW. Other information • Initial laboratory results from the National Laboratory have been inconclusive. They are retesting the samples. Some results will take a few days to be reported. • The age range of patients is 21-65. No risk factors have been identified. Previous immunization with Influenza has not proven to be protective. 1015-1145 (Third stage) The risk assessment report should prompt players to send a notification to the IHR DO. There will be further communication between the IHR DO and NFP to facilitate this and to enable an EIS posting. For countries that have NOT sent a notification (this should be recorded on the exercise flow chart in the white boards) by 10:45, then inject 4.2 should be sent. Final words: Always use: "This is an exercise message" or "Exercise Exercise Exercise" before any communication; Remember to copy Exercise Control Control@wpro.who.int in all e-mail communications; Make sure that the e-mail is sent from the Simulator Mailbox. (not personal e-mail) i.e. check the "From" field; Record actions taken; and Be Creative and have fun!
Supp ortin g material: LINE LIST ING OF PATIENTS ATTENDING WOR KSH OP WHO PRE SEN TED TO ALMOND HOS PITA L
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ANN EX5 ffiR Communication Check Time Day 1: From 9:20a m Day 2: From 7:20a m Stt!ps 1. Call the NFP on their registered telephone number. • If that does not connect, then try: Alternative telephone numbers; Mobi le phone. • Try up to 3 times for each number. If they do not pick up or it does not connect, consider it failed. Cross the result (X) on the Results Matrix. Add any relevant remarks. When /if you reach the NFP, highlight the number that you successfully reached them on. Tick the result ( v") on the Results Matrix. · 2. If you have successfully reached the NFP) please go through the following script to check their other forms of communication (SMS, fax, e-mail, and check telecom number).
Script Hello, have I reached the Natio nallli R Focal Point for [&i?'"M tf¥J'~ Good ~rw.Pzl I {!fl~fir.B.~y} (please check time zone of the NFP you are callin g- page 3 of the Participants' guide) This is an exercise message. I am calling from the WHO WPRO IHR Exercise Crystal Administration support team.
I am calling to perfo rm a check of communications, to ensur e that you are receiving our IHR messages on your provi ded contact details. May I please check if you have received: The Pre-Exercise message, sent by SMS to your registered mobile phone number? (Sent about 1 hour before the comms check - 8:30am on Day 1, 6:30am on Day 2 Manila time. See page 3 of the Participants' Guide to convert to the local time of the NFP that you are talking to). A faxed exerc ise 'Media Report'? (faxed in the last 20 mins) (Sent just prior to the comms check) Have you been receiving exercise emails from our Exerc ise Management Team (Control and Simulators) in the past 30 mins? Exercise Control: Con.trol@wpro. who.i nt Simulator Simulator@wpro.who. int
Than k you very much and we hope you enjoy the exercise.
·.
·-
ANN EX6
PRE - EXE RCIS E MESSAGE AND CLO SING MESSAG Pleas e c~:mfirm if you have received this message Dear Exercise Participants,
E
Welcome to 'lHR Exerc ise Crystal 20 11'! We would like to thank you all for taking time from your busy schedules to participate in this activity, and to also appreciate your support for collaborative lliR capacity-b~ilding efforts in our region . The objectives of the 2011 Exercise are to: 4. Validate the accessibility of the National ffiR Focal Points and WHO ffiR Contact Point using registered contact details 5. Test Natio nallli R. Focal Point's assessment of public health events using the decision instrument contained in Annex 2 of the ffiR (2005) and its notification process 6. Test the use of teleconference as a means of communica tion to connect the National ffiR Focal Points at the end of the exercise Please find the following documents attached here for your information and reference during the exercise: PowerPoint briefing Participants' Guide (Fina l)- draft emailed on 25 Novem ber, final version attached here including contact list • Actio n Log, Probl em Log & Evaluation Form -Wor d versions of Annex es 1-3 of Participants' Guide. Please fill out durin g/after the exerci se For the purposes of the exercise there will be a simul ated country and a simul ated Public Health Unit. The simulated coun try is in the Western Pacific region and is called the 'Repu blic of Calam ansi'. • The simulated Publi c Healt h Unit is in your country and is called 'Almo nd Publi c Healt h Unit' , located in 'Alm ond Distr ict'. Almond PHU can be contacted on: Telephone: + (632) 528 9650 Fax: + (632) 528 9075 E-mail: Simulator@wpro.who.i nt
Exercise play will be over 4 hours, equivalent to 2 days in the scenario. After play, there will be a 1 hour teleconference. Due to time constraints you may have little time for detailed internal consultations. Instead, we highly recom mend that Playe rs focus on making decisions with the provided scenario inform ation and performing appropriate lliR communications. Expected communications durin g Exercise Play include: • Real funct ional comm unica tions : Between participatin g NFPs and the WHOIWPRO IHR Conta ct Point (with support from WHO Country Office staff if needed/relevant) • Simu lated , but also funct ional comm unica tions: Between participating NFPs and your local public health unit (PHU) (played by the Simulator during the exercise) • Othe r comm unica tions by 'pape r work ' (reco rding on the Actio n Log): e.g. between participating NFP ~d other government departments or ag~ncies
•
Internal discussions within the office of the NFP are encouraged: To facilitate game play
Key points to remember during exercise play: • • • Always start and end communication with 11 THIS IS AN EXERCISE l.\IIESSAGE 11 or 11 EXERCISE EXERCISE EXERCISE 11 Copy every email communication to Control@wpr o.who.int (this will assist the Controller to manage exercise play) The relevant WHO Country Office (if applicable) should be copied on all email communication between NFPs and WPRO IHR CP. Do not fight the scenario Close the loop if you have taken your action • • Do the paper work -log all your activities in the Action Log Sheet Enjoy the exercise! ·
NFPs may request assistance from WHO CO staff for IHR communications if needed •
The exercise may be suspended or terminated if it appears that a real-world emergency is taking place. The Controller will inform you accordingly. If you have any urgent questions of problems during the exercise, please contact Exercise Control
via email (Control@wpro.who.int) or telephone (+632 528 9035).
We look forward to your participation and wish you a challenging and enjoyable exercise. Thank you again and with best regards, Exercise Management Team On behalf of Dr Takeshi Kasai Responsible Officer WHO lliR Contact Point in the Western Pacific Region Director, Division of Health Security and Emergencies WHO Western Pacific Regional Office
CLOSING MES SAG E
Dea r Exercise Participants, Than k you and congratulations for your conc lusion of IHR Exercise Cryst::t1 ?.0 111
We hope that you found the Exercise challengi ng, and also found the time to enjoy yourselve s and have some fun. Plea se take the time to fill out the Acti vity Log, Prob lem Log and Eval uatio n Form (by 4 December, to Control@wpro.who.int) , as we will use your feedback and suggestio ns to develop the 2012 IHR Exercise. An Exercise Report will be written in the com ing weeks, including the results of your feed back and comments from the Evaluator, and will be share d with you as s?on as possible. Again, we would like to express our sincere and warm appreciation for your efforts, and look forward to working with you on future lliR activities in our region. With best regards, Exercise Man agem ent Team On beha lf of Dr Tike shi Kasai Responsible Officer WH O lliR Con tact Poin t in the Wes tern Paci fic Region Director, Division of Heal th Security and Eme rgencies WH O Wes tern Pacific Regional Office
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EXAMPLE OF NOTI FICA TION Example of notification by country (edited) Dear WHO, In accorda nce with article 6 ofthe Internat ional Health Regulat ions (2005) country wishes to advise the WHO of an inciden t describ ed below. Situati on Calama nsi haS previou sly notified the WHO of an illness of unknow n origin. The Almond District Public Health Unit is managi ng an outbrea k with epidem iologica l link to the event in Calamansi. On 30 Novem ber 2011, 3 delegates attendin g an international worksh op at Hotel Lemoni a at the resort towri of Almond present ed tc Almond Hosp{ta l with an lnfluenza~like illness (ILI). Age range 21 -54 years. All3 cases were treated with Oseltam ivir and support ive therapy . Despite initial improv ement, their clinical c~mdition deterior ated after 12~24 hours of admissi on. All 3 cases develop ed severe neurolo gical sympto ms with progres sive loss of neurolo gical ~ction. One case died and the other 2 cases are in serious condition in the Intensiv e Care Unit. Twelve hours after the initial 3 cases present ed to Almond hospital, 13 other worksh op particip ants present ed to the same hospita l with sympto ms of an ILl. All cases .were admitte d and treated witl\ Oseltamivir and support ive therapy. Their present ing sytnp~oms were general ly mild, but 2 cases subsequ ently develop ed neurolo gical sympto ms and were transfer red to the ICU. They are in stable condition. Of these 13 patients, 11 others are being monito red closely. Of the 16 patients , three are Calamansi nationals. Two of these Calama nsi patients shared a room at the hotel. There are two other delegates attendin g the worksh op from Calamansi who remain asympto matic. Intervie ws of the 13 patients (who present ed with sympto ms 12hour s after the initial cases present ed) have found that 10 of them reside at the same wing of the hotel. The 3 other cases had spent a lot oftime with one of the ill Calamansi cases at a functio n after the conference. Case Fatality Ratio6% (1 out of 16 cases); Incubat ion period (based en 13 cases) 12~24 hrs; Progres sion to neurolo gical disease~ 25%. (4 out of 16 cases). Prelimi nary laborato ry testing has failed to identify a cause of their illness. Rapid Point of Care testing for influenz a has been negative. All other particip ants and all hotel staff are currently quarant ined at the hotel. There have been no reports of illness so far among those who were quarantined. All quarant ined particip ants and J;totel staff have been fully coopera tive. Laborat ory testing of nasopha ryngeal swabs and serum samples on all ~ases has been undertaken. Additio nal samples have been sent to the Nationa l Diagno stic Laborat ory for repeat testing and testing
for other viruses. Enhanced surveillance has been implemented in surrounding districts and rio reports of increased ILl or outbreaks have been reported. Media messages have been sent to the public to advise them of precautions and to present early to the hospital if symptomatic. Rationale for lliR Notification Serious Public Health Impact: unknown Unusual or Unexpected: Yes International disease spread: Yes Interference with international travel or trade: Yes 1) The public health impact does not appear serious at this stage. The risk assessment from the Almond PHU indicates a moderate risk. The illness appears to be caused by an unknown agent. The illness appears to be contained amongst the delegates who all stayed at the same location. The illness appears to be respiratory spread, however, the transmissibility of the disease appears to be low. There is ·no further evidence of transmission, enhanced surveillance has failed to identifY any further cases. There is evidence that some treatments (oseltamivir) has failed, but this is not conclusive. 2) The event is unexpected. The disease outbreak is caused by a potentially unknown organism or an unusual strain of influenza. The evolution of cases is more severe than expected for influenza. 3) There is a risk of international spread. Evidence indicates that the disease has already spread from Calamansi to the country. However, the local PHU advises that the probability of further spread is unlikely. We have also been notified that two international delegates, who were symptomatic, have breached quarantine with the intention of returning to their home country. 4) There is potentially a risk of international travel or trade restriction. The event has attracted significant attention from the international community and media; the event has also occurred at an international gathering. .Public Health Actions
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Country is monitoring the situation and liaising with Almond PHU. Passing on the results of the Almond PHU to WHO to further inform PHEIC risk assessment. Notifying WHO in accordance with the IHR 2005.
EXAM PLE OF AN EIS POST ING Example of an EIS posting by a participa ting country
EIS posting on cluster of respiratory illness among international delegates attending a worksho p at the Lemonia Hotel in the Almond district in name of country Current Risk Assessm ent Serious Public Health Impact: Yes Unusual or Unexpected: Yes International disease spread: No Interference with international travel or trade: No Risk Assessm ent Comme nts Serious public health impact: patients are presenting with unexpected symptoms. They are presenting with features similar to influenza and 25% progress to devel.op neurological symptoms. Suspected pathogen appears to have potential to cause epidemic and disease appears to be serious and is causing deaths, and also requiring central level assistance. Unusual or unexpected: the disease outbreak is caused by a potentially unknown organism , or an unusual strain of influenza. Patients are also presenting with unusual symptoms. International disease spread: the likelihood that the disease will spread in Almond District and neighboring districts or internationally is UNLIKELY based on current risk assessment.
Interference with international travel or trade - Nil. Event update 1 Decemb er 2011 On 30 November 2011, 3 delegates attending an international workshop at Hotel Lemonia at the resort town of Almond presented to Almond Hospital with an Influenza-Like Illness (ILl). Age range 21-54 years. All3 cases were treated with Oseltamivir and supportive
therapy. Despite initial improvement, their clinical condition deteriorated after 12-24 hours of admission. All 3 cases developed severe neurological symptoms with progressive loss of neurological function. One case died and the other 2 cases are in a serious condition in the Intensive Care Unit. Twelve hours after the initial 3 cases presented to Almond hospital, 13 other workshop participants presented to the same hospital witt symptoms of an ILL All cases were admitted and treated with Oseltamivir and supportive therapy. Their presenting symptoms were generally mild, but 2 cases subsequently developed neurological symptoms and were transferred to the ICU. They are in a stable condition. Of these 13 patients, 11 others are being monitored closely. Of the 16 patients, three are Calamansi nationals. Two of these Calamansi patients shared a room at the hotel.Tere are two other delegates attending the workshop from Calamansi who remain asymptomatic. Interviews of the 13 patients (who presented with symptoms 12 hours after the initial cases presented) have found that 10 of them resiC.e at the same wing of the hotel. The 3 other cases had spent a lot of time with one of the ill Calamansi cases at a function after the conference. Case Fatality Ratio- 6% (1 out of 16 cases); Incubation period (based on 13 cases)- 12-24 hrs; Progression to neurological disease- 25% (4 out of 16 cases). Preliminary laboratory testing has failed to identify a cause of their illness. Rapid point of care testing for influenza has been negative. All other participants and all hotel staff are currently quarantined at the hotel. There have been no reports of illness so far among those who were quarantined. All quarantined participants and hotel staff have been fully cooperative. Laboratory testing of nasopharyngeal swabs and serum samples on all cases has been undertaken. Additional samples have been sent to the National Diagnostic Laboratory for repeat testing and testing for other viruses. Enhanced surveillance has been implemented in surrounding districts and no reports of increased ILl or outbreaks have been reported. Media messages have been sent to the public to advise them of precautions and to present early to the hospital if symptomatic.