Exercise Panstop 2014 : exercise evaluation report, Manila, Philippines, 18-19 February 2014

WPDSE1408728 English only EXERCISE PANSTOP 2014 EXERCISE EVALUATION REPORT A rapid containment exercise on pandemic influenza of World Health Organization Regional Office for the Western Pacific Manila, Philippines 18–19 February 2014 Not for sale Printed and distributed by: World Health Organization Regional Office for the Western Pacific Manila, Philippines 14 April 2014 NOTE The views expressed in this report are those of the participants in PanStop 2014 and do not necessarily reflect the policies of the World Health Organization. This report has been prepared by the WHO Regional Office for the Western Pacific for those who participated in PanStop 2014, held in Manila, Philippines, from 18 to 19 February 2014. SUMMARY On 18 and 19 February 2014, the World Health Organization (WHO) Regional Office for the Western Pacific, in cooperation with the Japan International Cooperation System (JICS), held a PanStop exercise. It was the seventh such exercise designed to practice, validate and strengthen various aspects of and procedures related to communication, coordination and decision-making during a routine rapid response and prior to the launch of a rapid containment operation, with the intention of stopping or slowing the spread of a potentially pandemic influenza outbreak. The scenario depicted an outbreak in Domina, a hypothetical country in the Western Pacific Region, with consequent opportunities to contain the outbreak by way rapid response and rapid containment. The exercise was designed for WHO staff to become familiar with the rapid containment decision-making process and to understand the roles and responsibilities associated with rapid containment. CONTENTS SUMMARY 1. INTRODUCTION ............................................................................................................................. 6 1.1 Purpose ............................................................................................................................... 7 1.2 Objectives ........................................................................................................................... 7 2. EXERCISE SCENARIO ................................................................................................................... 7 2.1 Scenario .............................................................................................................................. 8 2.2 Master Sequence of Events List ....................................................................................... 8 2.3 Management ....................................................................................................................... 8 2.4 Assumptions ....................................................................................................................... 9 2.5 Artificialities ...................................................................................................................... 9 3. PRECEEDINGS .............................................................................................................................. 10 3.1 Conduct ............................................................................................................................. 10 3.2 Exercise ............................................................................................................................ 10 3.3 Debriefing and evaluation ............................................................................................... 10 4. PARTICIPANT EVALUATIONS ................................................................................................. 10 4.1 Rapid response operation ................................................................................................ 10 4.2 Rapid containment operation .......................................................................................... 11 4.3 Additional information/training ...................................................................................... 11 4.4 Strengths and areas for improvement ............................................................................. 12 5. FINDINGS AND CONCLUSIONS ............................................................................................... 13 5.1 Exercise ............................................................................................................................ 13 5.2 Rapid containment ........................................................................................................... 13 6. RECOMMENDATIONS ................................................................................................................ 13 APPENDIX 1: LIST OF ACRONYMS ............................................................................................. 15 ANNEX 1: COUNTRY PROFILE ..................................................................................................... 17 ANNEX 2: SCENARIO ...................................................................................................................... 19 ANNEX 3: LINE LIST ....................................................................................................................... 23 ANNEX 4: MASTER SEQUENCE LIST OF EVENTS .................................................................. 25 ANNEX 5: SELET INJETIONS ........................................................................................................ 37 ANNEX 6: PARTICIPANTS’ HANDBOOK ................................................................................... 49 ANNEX 7: EVALUATION FORM ................................................................................................... 59 Keywords: Disease outbreaks / Influenza, human / Pandemics / Risk Management – standards / Health personnel - education - 6 - - 7 - 1. INTRODUCTION 1.1 Purpose The purpose of the exercise is to assess the preparedness for staff members of the Division of Health Security and Emergencies (DSE), World Health Organization (WHO) Regional Office for the Western Pacific Regional Office to evaluate the need for and initiate a rapid containment operation with the intention of stopping or slowing the spread of a potentially pandemic influenza outbreak. 1.2 Objectives The objectives of Exercise PanStop 2014 were: (1) To assess capacity to initiate and conduct timely risk assessments; (2) To assess process of activating the emergency operations centre (EOC) in harmony with the emergency response framework (ERF); (3) To validate established decision-making processes for initiation of rapid containment; (4) To practice development and implementation of risk communications; (5) To ensure understanding of procedures for mobilization of Asia-Europe Foundation (ASEF) stockpiles; (6) To verify established coordination and communication arrangements between WHO and the Japan International Cooperation System (JICS); and (7) To test the responses of DSE staff throughout the rapid containment decision-making process. 2. EXERCISE SCENARIO PanStop 2014 was designed as a two-day modified functional table-top exercise. The focus was on the decision-making process and response during a routine rapid response and prior to the launch of a rapid containment operation. The exercise was a modified functional exercise based on a fictional scenario. The exercise was interactive, requiring participants to respond to each other in the roles designated for them in their duty statements, and was conducted under time constraints that were similar to, or even more challenging than, a real event. No actual movement of human or physical resources was required. - 8 - Exercise players were required to work from their designated operations centre or regular work environment and should be guided by their existing plans and procedures where appropriate. 2.1 Scenario The exercise depicted an outbreak of a disease in a hypothetical country, Domina, with consequent opportunities to contain the outbreak by utilizing stockpiles of antiviral medication and non-pharmaceutical interventions. The exercise scenario, epidemiological data and events introduced were based on previous PanStop exercises but modified specifically for PanStop 2014. The profile of the hypothetical country is attached as Annex 1, and the full scenario is attached as Annex 2. The scenario opened with an outbreak of unknown origin among villagers and pigs in Kisana, a northeast region of Domina with borders on China and Viet Nam. The outbreak was primarily diarrhoeal, and investigations by the Ministry of Health with rapid response support from WPRO later identified the source as Salmonella enterica subsp. choleraesuis linked to illegally-imported poultry consumed during Chinese New Year celebrations. Several cases of severe acute respiratory infection were also identified during the outbreak; two of these – a pig farmer who cooked for the new year celebration and his newphew – were confirmed positive for avian influenza A(H7N9) by polymerase chain reaction (PCR). A month after resolution of the initial outbreak, a large pig die-off was reported in Kisana. Investigations revealed several cases of influenza-like illness and severe acute respiratory infection, but the laboratory reported a possible problem with testing after several samples were PCR-positive for H7 but negative for N9. With assistance from the WHO Collaborating Centre in China, a novel influenza virus A(H7N13) was identified in these samples and was later also identified in samples from the capital city and another region of the country. The virus was a reassortment of avian influenza A(H7N9) virus and a swine influenza virus, believed to have reasserted in the pig herd belonging to the farmer who was first identified with avian influenza A(H7N9). WPRO responded and worked with the Ministry of Health to assess the feasibility of and then implement rapid containment measures. A line list containing epidemiologic and laboratory data for affected patients is included in Annex 3. 2.2 Master Sequence of Events List The Master Sequence of Events List (MSEL) is a list of all the scheduled simulated events that were injected into the exercise and the expected actions following each event in the scenario. Events were designed to achieve the exercise objectives. A copy of MSEL is attached as Annex 4. Select injections are included in Annex 5 to give an example of the means through which information about simulated events was provided. 2.3 Management The exercise was managed and controlled by an exercise management team. The primary responsibilities of the exercise management team were to monitor, manage and control the - 9 - exercise activity to meet the stated objectives. The exercise management team also developed the exercise materials in collaboration with WHO administrative staff in the Regional Office. The exercise management team was composed of the following people: Controller: Dr Erica Dueger Simulators: Dr Li Ailan, Dr Chin Kei Lee, Ms Katherine Horton Evaluator: Ms Naoko Ochiai, Ms Katherine Horton Specific responsibilities of management team and player’s functions are identified in the players’ handbook, which is attached as Annex 6. 2.4 Assumptions The following assumptions were made in order to ensure that the exercise was as realistic as possible: (1) Exercise events were intended to progress in a logical and realistic manner in order to achieve exercise objectives. (2) Players were knowledgeable about organization response plans and procedures and their assigned roles and responsibilities within them. (3) Controllers and simulators used simulated data and information support sources. (4) Players responded in accordance with existing procedures, plans, and policies. In the absence of appropriate written instructions, players used their own initiative to satisfy response requirements. All actions were recorded in an action log, which is attached within Annex 6. 2.5 Artificialities Players encountered some artificialities and constraints resulting from the simulated scenario. Players were encouraged to accept these artificialities as they were necessary to achieve exercise objectives. (1) The exercise was played in compressed time. Over the eight-hour period of the exercise, events in the scenario depicted several days of simulated activity. This had an effect on the amount of time allowed for decision making and is accounted for in the evaluation process. (2) Because of the limited time available in which to conduct the exercise, “time jumps” occurred, meaning that the elapsed time between consecutive events may have represented several hours or even days. At various times exercise time slowed to allow for more time for discussion and decision making. The exercise controller ensured that all players were aware of changes in exercise time. (3) Responses obtained by players from simulations (both verbal and written) may not have been of the quality or detail available from the real organization or individual. - 10 - (4) Actions that would normally require deployment of personnel or resources were involved; however, no live movement of personnel or material was required. (5) Simulation occurred during the exercise to compensate for non-participating individuals or organizations including WHO headquarters (HQ), relevant government authorizations, external organizations, citizens of the community and others. 3. PRECEEDINGS 3.1 Conduct Participants played out their roles and responsibilities in Situation Room 403 in WHO WPRO. The exercise management team operated out of the same room. 3.2 Exercise The exercise took place from 18 to 19 February 2014. Day 1 commenced at 09:00 PHT (GMT+8), immediately following the morning meeting, and was suspended at 13:00 PHT (GMT+8). Day 2 also commenced at 09:00 PHT (GMT+8), immediately following the morning meeting and also ended at 13:00 PHT (GMT+8). A total of eight hours of simulated activities were representative of a fictional 42-day period (including a 28-day “time lapse”). The exercise ended with all objectives and anticipated actions sufficiently addressed. A total of 31 scheduled injects were provided to the participants by e-mail, telephone and verbally. 3.3 Debriefing and evaluation A debriefing session was held for all participants the day after the exercise ended; this session commenced at 09:00 PHT (GMT+8), immediately following the morning meeting, and was suspended at 13:00 PHT (GMT+8). Dr Ailan Li and Dr Erica Dueger chaired the meeting. All of the participants were requested to submit an evaluation form to the exercise management team to share their feelings and comments about the exercise, which is attached as Annex 7. 4. PARTICIPANT EVALUATIONS 4.1 Rapid response operation (1) I understand my normal role in a rapid response operation. - 11 - Average response: 4.5/5.0 (range 4.0 – 5.0) (2) This PANSTOP exercise helped me practice and understand more fully my role in a rapid response operation. Average response: 4.5/5.0 (range 4.0 – 5.0) (3) This PANSTOP exercise helped me practice and understand more fully others’ roles in a rapid response operation. Average response: 4.5/5.0 (range 4.0 – 5.0) (4) Following this exercise I better understand logistics necessary to support a rapid response operation. Average response: 4.5/5.0 (range 4.0 – 5.0) 4.2 Rapid containment operation (1) I understand my normal role in a rapid containment operation. Average response: 4.75/5.0 (range 4.0 – 5.0) (2) This PANSTOP exercise helped me practice and understand more fully my role in a rapid containment operation. Average response: 5.0/5.0 (range 5.0 – 5.0) (3) This PANSTOP exercise helped me practice and understand more fully others’ roles in a rapid containment operation. Average response: 4.5/5.0 (range 4.0 – 5.0) (4) Following this exercise I better understand logistics necessary to support a rapid containment operation. Average response: 4.0/5.0 (range 3.0 – 5.0) 4.3 Additional information/training I feel I need additional information/training in (please circle all that apply) (a) Risk assessments – circled by 25% of participants (b) EOC operations – circled by 50% of participants (c) ERF as it relates to DSE – circled by 50% of participants - 12 - (d) Criteria for activation of stockpiles – circled by 25% of participants (e) None of the above – circled by 0% of participants (f) Other (please describe) – circled by 0% of participants 4.4 Strengths and areas for improvement Strengths of the PanStop 2014 exercise: “Well-designed, complex scenario” “Scenario was quite refreshing (not H5N1)” “Good opportunity to understand the tasks in an emergency response operation” “Helped me imagine how real pandemic happens and how to manage the situation” “Opened for discussion how the different existing frameworks (ERF, IHR, SOPs, etc) could be better harmonised at the operation level” Areas for improvement in PanStop 2015: “Start with a sitrep [to] focus on containment discussion [and] allow time for discussions” “Focus more on the logistics and decision making” “Involve [external] stakeholders more” “Functional roles...need to be addressed more consistently and thoroughly” “Internal information sharing to make sure everyone involved understand the situation, what they are dealing with, what task the other members are doing, etc.” Strengths of general EOC operations: “Roles [are] clearly defined” “Good technical equipment for documentation” Areas for improvement in general EOC operations: “Familiarity [with] rapid containment guidelines and the EOC SOP” “Manual for...equipment (e.g., electronic white board, TV) would be helpful” - 13 - 5. FINDINGS AND CONCLUSIONS 5.1 Exercise Several positive outcomes were noted at the close of the exercise. Players worked well together, interacting respectfully and professionally throughout the exercise. Players also thought creatively through the exercise process, asking good questions to simulators and responding with many of the expected actions. Responses were impressive, especially considering that this was the first PanStop exercise for many of the players. The exercise was well-developed and well-planned; however, the quantity of information provided was so great that it was difficult for players to process the information provided in the time provided. The second day of the exercise went more smoothly than the first once players had a better understanding of the design of the exercise. 5.2 Rapid containment Players conducted rapid risk assessments and worked through the decision-making process for rapid containment to successfully achieve the goals of the exercise. However, players did not seem to fully understand the concept and process of rapid containment and the roles for all key teams such an operation. There was also confusion about the relationships between response steps including ERF grading, International Health Regulations (IHR) notification and declaration of a public health event of international concern (PHEIC). 6. RECOMMENDATIONS (1) Expand guidance for rapid containment Expand decision-making tools for rapid containment to clarify steps and add more detail to required processes, specifically by: (a) Specifying operational feasibility questions, including inter-sectoral components with input from experts in health systems, logistics and humanitarian emergencies, and (b) Adding details required for stockpile calculations, including duration of prophylaxis course, age-specific dosage recommendations and required components of personal protective equipment components and use. - 14 - Clarify relationship between response frameworks including rapid response, rapid containment, ERF grading, IHR notification and PHEIC declaration. (2) Provide training on the role of JICS in rapid containment Invite JICS to present their role in rapid containment and clarify the difference between “mobilizing” and “launching” the stockpile. (3) Tailor future exercises to participants’ experience Reduce the quantity of information provided in the exercise and tailor expectations to the participants’ prior experience with similar exercises. This could be achieved by providing more information about the first stages of the outbreak as initial background documentation to allow more time for rapid containment decision-making and related processes. (4) Improve exercise introduction document Clearly define which responses and communications should be simulated by participants and which require concrete outputs. Recommend increased verbal communication among players to allow quicker feedback from simulators. Assign roles among players to ensure all tasks are monitored and limit overlap (e.g., someone to monitor email, someone to track players’ actions, someone to act as team lead). Provide a copy of the DSE Event Management Quickstart Checklist (EOC SOP p. 15) and Overview of Rapid Containment (Generic Protocol for Rapid Containment p. 2) as specific guidance for exercise responses. (5) Focus exercise on slowing the outbreak Consider focusing the exercise on slowing the spread rather than fully stopping the spread of a potentially pandemic influenza outbreak. - 15 - APPENDIX 1 LIST OF ACRONYMS ASEAN Association of Southeast Asian Nations DSE Division of Health Security and Emergencies EOC Emergency Operations Centre ERF Emergency Response Framework HQ Headquarters IHR International Health Regulations JICS Japan International Cooperation System MSEL Master Sequence of Events List PCR Polymerase Chain Reaction PHEIC Public Health Event of International Concern WHO World Health Organization WPRO Western Pacific Regional Office - 16 - - 17 - ANNEX 1 COUNTRY PROFILE DOMINA Domina is a recently-established, independent landlocked country that borders China, Viet Nam and Laos. Domina is geographically isolated by mountainous borders, with a single small airport on the outskirts of the main city, Domina; only two paved roads lead in and out of Domina. These roads pass through the regions of Nandali and Litala; other regions are connected to the capital city by roads that do not extend beyond the country’s borders. Approximately half of the population (143,427 as of the 2012 census) lives in the city of Domina, while the other 50% are divided among five rural, agricultural communities. The age structure is as follows: 36% 0-14 years, 21% 15-24 years, 34% 25-54 years, 5% 55-64 years and 4% 65 years and older. Domina is well known for its unique breed of pot- bellied pigs, which are the primary export product of the country, essentially sustaining the entire gross domestic product (GDP per capita = US$1,400 in 2012). All pot-bellied pigs are raised in the 5 rural communities and brought directly through the airport quarantine facilities for export; no live pigs are allowed within the city limits of Domina. Due to the importance of the pot-bellied pig industry, Domina has not seen the rapid urbanization that has been common elsewhere in the world. The pot-bellied pigs are exported directly to the United States through the exotic pet trade market. They are also exported to research institutions worldwide because of their unique ability to act as a model for human infectious diseases, and their role in this field is growing following the discovery that they provide a better model than ferrets and monkeys. In order to protect the pot-bellied pig industry, visas are extremely difficult to obtain so tourism is essentially non- existent. The Government of Domina has been known to take extreme measures to protect the Domina - 18 - pot-bellied pig industry and already places significant limitations on citizens’ travel to and from the country. Pot-bellied pigs that do not meet the stringent export requirements of the international community are the primary source of protein for the population of Domina. To protect the pot- bellied pigs, raising and selling of live poultry is illegal in Domina. Poultry products are thus very expensive because they are imported fresh-frozen and must meet strict quarantine and testing procedures prior to arrival. During the Chinese New Year, the market for fresh-frozen poultry products in Domina grows significantly because celebrations include a delicious traditional local dish made from pork and chicken; this dish is so important that families have been known to mortgage their property in order to purchase chicken for this meal. Purchasing poultry products for Chinese New Year celebrations has been particularly challenging this year because the economy of Domina is suffering as a result of the global economic recession, which has cut back research funding and thus hurt the pot-bellied pig industry. There have been unconfirmed rumors of illegal live poultry transport into Domina through the mountains along the Chinese border. Domina is a member of the Association of Southeast Asian Nations and the World Health Organization (WHO) Western Pacific Region. Although it does not have a WHO country office, there is a WHO liaison office with a WHO liaison officer located in the capital city of Domina. The Ministry of Health (MOH) of Domina is small with a single surveillance officer who also serves as the IHR National Focal Point. The MOH of Domina has been following recent events of H7N9 in neighboring China with significant concern, especially as more and more human cases encroach on the borders of Domina. Since June 2013 they have invested significant resources to establish a robust severe acute respiratory infection surveillance (SARI) system at the Central General Hospital (CGH), the country’s only hospital which is small but has 10 intensive care beds, each with ventilator support. Each of the five rural communities also has a simple, but well-staffed, health center with robust influenza-like illness (ILI) surveillance. SARI samples are transferred to the Central National Laboratory (CNL) on a daily basis; ILI samples are stored at surveillance sites and sent to the CNL on a weekly basis. Surveillance results are reported electronically on a weekly basis and are linked with national ID numbers to laboratory results. Laboratory capacity in the country is focused at the CNL, which is located adjacent to CGH. The laboratory has a limited staff but is able to perform microscopy, bacteriology, serology and polymerase chain reaction, although extractions must be performed manually, and (due to limited resources) the testing protocol is limited to known circulating viral types; no sequencing capacity is available in country. Recently all staff members from the CNL attended an influenza lab training put on by WPRO in Singapore; primers are available for all seasonal subtypes as well as H5N1 and H7N9. Rural health centers have only basic microscopy capacity. - 19 - ANNEX 2 SCENARIO Day 0 – 7 February Local media in Domina has reported a large, mysterious outbreak in Kisana, a northeastern region of the country, in which a dozen people have died and nearly 200 others are sick. The sick are reported to be suffering from fever, diarrhoea and other symptoms, and some pot-bellied pigs in the area are showing signs of diarrheal disease and with a few also showing respiratory distress. Day 1 – 8 February The Ministry of Health (MOH) issues a preliminary report on the outbreak, which indicates that the majority of patients are suffering from diarrheal disease after attending a large feast, held in the village a week ago to celebrate the Chinese New Year. MOH also notes that there are a number of patients seeking care for influenza-like illness. Furthermore, three patients have been hospitalized at Central General Hospital in Domina – two with diarrhea and one with both diarrhea and severe acute respiratory infection (SARI). Day 2 – 9 February Two additional SARI patients from Kisana are admitted to CGH, and the patient previously admitted with both diarrhea and SARI has died. Initial stool culture results are also available from patients in Kisana. Of the 8 patients for whom viable samples were collected, transported to Domina and cultured at Central National Laboratory, Salmonella enterica subsp. choleraesuis was isolated from 3 samples. No other pathogens have been identified to date. The Ministry of Agriculture and Livestock confirms a concurrent outbreak among swine in Kisana, reporting that at least three herds have been affected – two located near the site of the new year’s celebration and one a short distance away. Day 3 – 10 February Laboratory results from the Central National Laboratory (CNL) for the patient admitted with both diarrhea and SARI indicate that the patient is RT-PCR-positive for avian influenza A(H7N9). MOH reports these findings to IHR and sends samples to the WHO Collaborating Center for Reference and Research on Influenza (CC) at the Chinese Center for Disease Control and Prevention (China CDC). In response, MOH establishes a Task Force for Pandemic Influenza and requests assistance from the World Health Organization (WHO) Western Pacific - 20 - Regional Office (WPRO) to support enhanced surveillance, to send medications and personal protective equipment (PPE) and to assist in preparations for a press conference. Another SARI patient is admitted, but this patient comes from Mosoro rather than Kisana and has no connection to Kisana. Case reports are available on all four SARI patients. Day 4 – 11 February MOH initiates contact tracing among family and neighbors of the SARI patients but is only able to identify one contact with a history of respiratory illness. This contact is the brother of the patient from Mosoro, who was treated for influenza-like illness (ILI) several days ago and diagnosed with pandemic influenza A(H1N1). Day 5 – 12 February Additional stool culture results from diarrhea patients in Kisana have identified Salmonella enterica subsp. choleraesuis in approximately 15% of samples. No other diarrheal pathogens have been identified, and all diarrhea cases have been linked to a traditional chicken dish served at a new year’s celebration in the village. Additional laboratory results indicate that the second SARI patient from Kisana is also RT-PCR- positive for avian influenza A(H7N9). MOH sends samples to China CDC for confirmatory testing. Day 6 – 13 February The WHO CC at China CDC confirms results for the first H7N9 patient. Laboratory results from CNL indicate that the SARI patient from Mosoro is infected with pandemic influenza A(H1N1). Contact tracing has found no additional cases of respiratory illness. Day 7 – 14 February The WHO CC at China CDC reports that the avian influenza A(H7N9) virus identified in Kisana is closely related to isolates from the Yunnan Province in southern China. • NOTE LAPSE IN EXERCISE TIME • Day 33 – 14 March - 21 - MOAG investigated reports of a number of deaths among a herd of pot-bellied pigs in Kisana and discovered that nearly half of a farmer’s herd had died over the past few weeks. Affected pigs are suffering from respiratory symptoms including cough, as well as rapid weight loss, fever and lethargy. In response to MOAG report, MOH report that no avian influenza A(H7N9) cases have been reported since the two identified in early February. However, there has been an increase in ILI cases over the past few days and several SARI patients were admitted to CGH. In response to the pig deaths in Kisana, the Government of Domina bans all international travel and orders all imports and exports to cease until further notice. Day 34 – 15 March CNL reports that it must have a problem with the avian influenza A(H7N9) testing protocol because samples from two SARI patients have given positive results for H7 and negative results for N9. The tests have already been repeated three times, so MOH requests assistance from WHO, noting that a recent power outage may have affected reagents. MOH sends sample to China CDC for confirmation. Three additional ILI cases are reported. Day 36 – 17 March Two additional ILI cases and one SARI case are reported. Day 37 – 18 March Four additional ILI cases and one SARI case are reported. Laboratory results from CNL are available for nine SARI and ILI cases – 2 influenza A (type not specified), 1 pandemic influenza A(H1N1), 5 influenza A(H7) and 1 influenza negative. Day 39 – 20 March China CDC has identified a novel influenza A(H7N13) in a SARI sample. MOH reports this case to IHR and requests in-country assistance to determine the extent of the spread of this virus and, if necessary, design and implement control measures. Two additional ILI cases are reported. Day 40 – 21 March - 22 - Local media reports on the new virus, calling it a “deadly virus” with potential for “much suffering.” MOH requests WHO assistance in preparing a comment to respond to this article. A WHO field team arrives in Domina and advises on rapid containment feasibility and requests additional staff and more antivirals and PPE. WHO begins discussing rapid containment with MOH. WHO also initiates a RC risk assessment, informs JICS, MOFA, ASEF, ASEAN and WHO HQ of start of risk assessment and begins discussing the containment zone and the necessary actions for RC operation. Day 41 – 22 March CGH is filled to capacity and flooded with patients who are concerned about the novel influenza A(H7N13) virus. MOH requests advice to address this issue and also to calm medical personnel concerns about their risk of contracting the virus. WHO holds a teleconference with its field team in Domina to discuss the RC risk assessment and decide on the containment zone. There is significant international media coverage of the new virus in Domina. An additional SARI patient is reported. Day 42 – 23 March WHO and MOH meet with the Task Force for Pandemic Influenza to make a final decision on whether to launch RC. Three additional ILI cases are reported. The national authority decides to move forward with RC to control the threat from the novel influenza A(H7N13) virus in Domina. - 23 - ANNEX 3 LINE LIST PART 1: AVIAN INFLUENZA (H7N9) Case # Sex Age Location Occupation Animal Contact Case Contact SARI/ ILI Date of Onset Date of Care Outcome Outcome Date Laboratory Result Result Date Case 1 M 42 Kisana Pig farmer Pigs, Poultry Cook at New Year's feast SARI 4-Feb-14 6-Feb-14 Death 9-Feb-14 H7N9 10-Feb-14 Case 2 M 26 Kisana Poultry seller Poultry Sold poultry to Case 1 SARI 5-Feb-14 8-Feb-14 Death 9-Feb-14 H7N9 12-Feb-14 Case 3 F 38 Kisana Housewife Pigs, Poultry Wife of Case 1 SARI 7-Feb-14 9-Feb-14 No sample Case 4 F 4 Mosoro Child No known No known SARI 9-Feb-14 10-Feb-14 Pending PART 2: NOVEL INFLUENZA A(H7N13) Case # National ID # Sex Age Location Occupation Animal Contact Case Contact SARI/ ILI Date of Onset Date of Care Outcome Outcome Date Laboratory Result Case 1 76-9482 M 38 Kisana Pig farmer Pigs Bought pigs from family of H7N9 SARI 4-Mar-14 7-Mar-14 Death 13-Mar-14 H7N13 Case 2 78-9374 F 36 Kisana Housewife Pigs Wife of 76-9482 ILI 6-Mar-14 8-Mar-14 Recovery H1N1 Case 3 90-8339 M 24 Kisana Laborer Pigs Nephew of 78-9374 ILI 6-Mar-14 8-Mar-14 Recovery Flu A Case 4 70-0004 F 44 Kisana Market vender Pigs Sells vegetables to 78-9374 ILI 7-Mar-14 9-Mar-14 Recovery No sample Case 5 47-9277 M 67 Kisana Retired Pigs Father of 70-0004 SARI 8-Mar-14 10-Mar-14 Death 14-Mar-14 H7N13 Case 6 89-2348 M 25 Kisana Unemployed Pigs Friend of 90-8339 ILI 9-Mar-14 10-Mar-14 Recovery H7 Case 7 00-2874 M 14 Kisana Student Pigs Neighbor of 89-2348 ILI 10-Mar-14 10-Mar-14 Recovery Flu A Case 8 12-9838 F 2 Kisana Young child Pigs Sister of 00-2874 SARI 10-Mar-14 12-Mar-14 Death 18-Mar-14 No sample - 24 - Case 9 82-1911 F 32 Domina Nurse Cared for 47-9277 ILI 12-Mar-14 13-Mar-14 Recovery H7 Case 10 02-9831 M 12 Kisana Student Pigs Classmate of 00-2874 ILI 13-Mar-14 14-Mar-14 Recovery H7 Case 11 84-9923 F 30 Domina Housewife Neighbor of 82-1911 ILI 13-Mar-14 14-Mar-14 Recovery H7 Case 12 05-2990 F 9 Domina Student Daughter of 82-1911 ILI 14-Mar-14 14-Mar-14 Recovery Negative Case 13 60-2295 M 54 Domina Cleaner Cleaned ward of 00-2874 SARI 14-Mar-14 15-Mar-14 Death 22-Mar-14 H7N13 Case 14 79-3392 F 35 Kisana Housewife Pigs Mother of 02-9831 ILI 14-Mar-14 16-Mar-14 Recovery Pending Case 15 77-2293 M 37 Domina Shop owner Husband of 84-9923 ILI 15-Mar-14 16-Mar-14 Recovery Pending Case 16 62-9380 F 52 Kisana Housewife Pigs Neighbor of 79-3392 SARI 16-Mar-14 17-Mar-14 Recovery H7N13 Case 17 61-9203 F 53 Domina Housewife Wife of 60-2295 ILI 17-Mar-14 17-Mar-14 Recovery Pending Case 18 52-6649 M 62 Domina Shop owner Business partner of 78-2293 ILI 17-Mar-14 18-Mar-14 Death 19-Mar-14 Pending Case 19 68-8332 F 46 Domina Seamstress Customer of 52-6649 ILI 18-Mar-14 18-Mar-14 Recovery Pending Case 20 06-1962 F 8 Domina Student Classmate of 05-2990 ILI 18-Mar-14 18-Mar-14 Recovery Pending Case 21 07-3742 F 7 Domina Student Classmate of 05-2990 ILI 18-Mar-14 19-Mar-14 Recovery Pending Case 22 04-8220 F 10 Domina Student Classmate of 05-2990 ILI 18-Mar-14 19-Mar-14 Recovery Pending Case 23 58-2831 M 56 Kisana Pig farmer Pigs Husband of 62-9380 ILI 19-Mar-14 21-Mar-14 Recovery Pending Case 24 86-2238 M 28 Kisana Pig farmer Pigs Nephew of 58-2831 ILI 20-Mar-14 21-Mar-14 Recovery Pending Case 25 10-3821 M 4 Nandali Young child Nephew of 68-8332 SARI 20-Mar-14 21-Mar-14 Recovery Pending Case 26 72-9382 F 42 Domina Teacher Neighbor of 68-8331 ILI 20-Mar-14 23-Mar-14 Recovery Pending Case 27 46-6639 F 68 Domina Retired Aunt of 61-9203 ILI 21-Mar-14 23-Mar-14 Recovery Pending Case 28 92-0045 M 6 Kisana Young child Pigs Son of 86-2238 ILI 21-Mar-14 23-Mar-14 Recovery Pending - 25 - ANNEX 4 MASTER SEQUENCE LIST OF EVENTS Inject # Inject Time Exercise Time Event Message From Message To Method Expected Action Team Lead Surveillance Team Logistics Risk Communications MONDAY, 17 FEBRUARY 2014 I01 15:00 Day 0 (7 Feb) Media picks up large, mysterious outbreak in Kisana Domina Daily All Email I02 15:30 Day 1 (8 Feb) Preliminary report on outbreak - mostly diarrhea, some ILI, one SARI (Case 1) WHO liaison officer All Email TUESDAY, 18 FEBRUARY 2014 I03 09:30 Day 2 (9 Feb) Two additional SARI patients admitted (Cases 2- 3); Case 1 dies WHO liaison officer All WHO morning meeting - Risk assessment - Ask liaison office for more information I04 09:40 Day 2 (9 Feb) MOAG confirms report of sick pigs WHO liaison officer All Email I05 09:45 Day 2 (9 Feb) Stool culture results show S. enterica subsp. choleraesuis WHO liaison officer All Email - Update risk assessment - 26 - Inject # Inject Time Exercise Time Event Message From Message To Method Expected Action Team Lead Surveillance Team Logistics Risk Communications I06 09:55 Day 3 (10 Feb) Case 1 is RT-PCR positive for H7N9 WHO liaison officer All Email - Activate EMT - Facilitate sample to be sent to WHO CC for confirmation - Brief DSE director - Urge MOH to notify IHR - Urge MOH to share information with MOAG - Update risk assessment - Start linelist - Ask liaison office for more information I07 10:05 Day 3 (10 Feb) MOH notifies IHR, sets up Task Force for Pandemic Influenza and requests WHO support (active surveillance, press conference, antivirals and PPE) IHR NFP All Email - Discuss whether to deploy epi support - Discuss whether to deploy antivirals and PPE from WPRO stockpile - Prepare EIS posting - Prepare pre- departure checklist for WHO staff - Check health of WLO staff - Request logistics details from liaison officer - Prepare basic logistics overview of Kisana - Provide flight schedule, local transport, custom clearance - Support crafting of message for press conference - 27 - Inject # Inject Time Exercise Time Event Message From Message To Method Expected Action Team Lead Surveillance Team Logistics Risk Communications I08 10:20 Day 3 (10 Feb) One additional SARI patient admitted (Case 4) and reports available for Cases 1-4 WHO liaison officer Surveillance team Email - Regularly share information with HQ - Update risk assessment - Update linelist - Ask liaison office for more information I09 10:30 Day 4 (11 Feb) MOH initiates contact tracing in Kisana WHO liaison officer Surveillance team Email I10 10:40 Day 5 (12 Feb) Case 2 is RT-PCR positive for H7N9 WHO liaison officer All Email - Facilitate sample to be sent to WHO CC for confirmation - Update linelist I11 10:50 Day 5 (12 Feb) Stool culture results show S. enterica subsp. choleraesuis; questionnaire links cases to chicken dish with routine ILI; swine results WHO liaison officer Surveillance team Email - Analyze ILI report - Note that outbreak is food- borne (unrelated to H7N9) I12 11:00 Day 6 (13 Feb) WHO CC confirms Case 1 is RT-PCR positive for H7N9 WHO liaison officer All Email I13 11:10 Day 6 (13 Feb) Case 4 is RT-PCR positive for H1N1 WHO liaison officer Surveillance team Telecom (followed by email) - Update linelist - Note this case seems unrelated to others - 28 - Inject # Inject Time Exercise Time Event Message From Message To Method Expected Action Team Lead Surveillance Team Logistics Risk Communications I14 11:20 Day 7 (14 Feb) Sequencing results links H7N9 to Yunnan Province; Case 2 confirmed H7N9 WHO liaison officer All Email • NOTE LAPSE IN EXERCISE TIME • I15 11:30 Day 33 (14 Mar) MOAG reports outbreak among pigs in Kisana WHO liaison officer Surveillance team Email - Ask liaison office for updated information I16 11:45 Day 33 (14 Mar) MOH report shows spike in ILI cases (1-4, 6-7, 9) and two SARI patients admitted (Cases 5, 8) WHO liaison officer Surveillance team Email - Risk assessment - Consider linelist - Inquire further information about cases I17 12:00 Day 33 (14 Mar) Ban on import, export and travel Domina Daily All Email I18 12:10 Day 34 (15 Mar) Three additional ILI cases (Cases 10-12) WHO liaison officer Surveillance team Telecom (followed by email) - Consider linelist - Inquire further information about cases - 29 - Inject # Inject Time Exercise Time Event Message From Message To Method Expected Action Team Lead Surveillance Team Logistics Risk Communications I19 12:20 Day 34 (15 Mar) Lab reports problem with H7N9 testing and requests assistance WHO liaison officer All Email - Recommend sending samples to WHO CC - Coordinate with WHO CC to send new set of primers/probes - Prepare pre- departure checklist for WHO staff I20 12:30 Day 36 (17 Mar) Two additional ILI cases (Cases 14- 15) and one additional SARI case (Case 13) WHO liaison officer Surveillance team Telecom (followed by email) - Consider linelist - Inquire further information I21 12:40 Day 37 (18 Mar) One additional SARI patient admitted (Case 16) and four additional ILI cases (Case 17-20) WHO liaison officer Surveillance team Telecom (followed by email) - Consider linelist - Inquire further information - 30 - Inject # Inject Time Exercise Time Event Message From Message To Method Expected Action Team Lead Surveillance Team Logistics Risk Communications WEDNESDAY, 19 FEBRUARY 2014 I22 09:30 Day 39 (20 Mar) WHO CC identifies Case 5 as novel H7N13 WHO liaison officer All Email - Activate EOC with EMT - Facilitate sample to be sent to WHO CC for confirmation - Brief DSE director - Urge MOH to notify IHR - Urge MOH to share information with MOAG - Update risk assessment I23 09:45 Day 39 (20 Mar) MOH notifies IHR about event and requests in-country support IHR NFP All Email - Discuss whether to deploy epi support - Discuss deployment of lab support from WHO CC - Prepare EIS posting - Prepare pre- departure checklist for WHO staff - Check health of WLO staff - Deploy antivirals and PPE from Regional Office warehouse - Start considering mass distribution plan with team - 31 - Inject # Inject Time Exercise Time Event Message From Message To Method Expected Action Team Lead Surveillance Team Logistics Risk Communications I24 10:00 Day 39 (20 Mar) Two additional ILI cases (Cases 21- 22) WHO liaison officer Surveillance team Email - Consider RC - Discuss size of WHO team to conduct RC feasibility assessment (consider requesting GOARN deployment if not enough staff) - Develop feasibility questions for field team - Regularly share information with HQ - Update linelist - Prepare pre- departure checklist for WHO staff - Check health of WLO staff I25 10:20 Day 40 (21 Mar) MOH requests support in response to media report on new virus IHR NFP All Email - Support crafting of message for press conference - 32 - Inject # Inject Time Exercise Time Event Message From Message To Method Expected Action Team Lead Surveillance Team Logistics Risk Communications I26 10:30 Day 40 (21 Mar) Laboratory and epidemiology staff arrive; two additional ILI cases (Cases 23- 24) and one additional SARI case (Case 25) Field team All Telecom - Urge discussions about RC with national authority - Initiate RC operational feasibility assessment and possible RC operation (D-1) - Inform JICS / MOFA / ASEF / ASEAN / HQ of start of risk assessment - Start discussing containment zone and the necessary actions for RC operation - Update linelist - Prepare talking points for RC - 33 - Inject # Inject Time Exercise Time Event Message From Message To Method Expected Action Team Lead Surveillance Team Logistics Risk Communications N/A 11:00 Day 40 (21 Mar) Field team advises on RC feasibility and requests additional staff and more antivirals and PPE Field team All Telecom - Decide to mobilize Singapore regional stockpile and inform JICS / MOFA / ASEF (D- 2) - Advise JICS on the approximate quantities of antivirals and PPE for rapid containment - Prepare necessary actions for RC, including operational issues - Prepare to send WHO staff for additional support - Confirm logisticians as part of field team - Discuss the mass distribution plan with team I27 11:20 Day 41 (22 Mar) CGH reports it is full and worried about spread of infection and staff use of PPE IHR NFP All Telecom - Update linelist - Check on the safety and security of team - Give a heads up ASEF stockpile being prepared to fly - Prepare talking points for hospital leadership - 34 - Inject # Inject Time Exercise Time Event Message From Message To Method Expected Action Team Lead Surveillance Team Logistics Risk Communications N/A 11:40 Day 41 (22 Mar) WHO field team discusses RC feasibility and asks how to decide extent of containment zone Field team All Telecom - Hold teleconference to get more info about RC risk assessment - Discuss and decide on containment zone - Provide advice on the feasibility of RC and containment zone - Check warehouse, transport, re- distribution, JICS custom clearance and final RC distribution plan - Confirm logistics in the containment zone including distribution plans I28 12:00 Day 41 (22 Mar) International media report the situation widely Int'l media All Email - Discuss and provide international media relations plan I29 12:10 Day 42 (23 Mar) WLO requests meeting to discuss feasibility assessment findings WHO liaison officer All Email - Schedule meeting - Start preparing an announcement by MOH to launch RC operation I30 12:20 Day 42 (23 Mar) Three additional ILI cases (Cases 26-28) WHO liaison officer Surveillance team Email - Update linelist - 35 - Inject # Inject Time Exercise Time Event Message From Message To Method Expected Action Team Lead Surveillance Team Logistics Risk Communications N/A 12:30 Day 42 (23 Mar) Meeting to discuss final decision on RC Task Force for Pandemic Influenza, Field Team, WPRO Surveillance team Telecom - Make final decision on whether or not to launch RC (D-3) - Recommend that WHO Director- General announce to media decision to launch RC - Check on safety of field team - Plan for team retrieval - Prepare a talking point for launching RC in coordination with HQ I31 12:55 Day 42 (23 Mar) MOH informs Regional Office that the national authority has decided to launch RC IHR NFP All Email Exercise ends THURSDAY, 20 FEBRUARY 2014 N/A 09:30 N/A Debriefing on exercise and rapid containment All Verbal - 36 - - 37 - ANNEX 5 SELECT INJETIONS EVENT INJECT FORM EVENT ID SCHED TIME INJECT MEANS CONTROLLER I02 15:30 Email PRIORITY DESCRIPTION OF EVENT Preliminary report from Kisana outbreak Actual inject time: Exercise time: 8 February FROM: WHO liaison officer INFO: TO: All SUBJECT PRELIMINARY REPORT ABOUT OUTBREAK IN KISANA THIS IS AN EXERCISE MESSAGE Dear WPRO, Following yesterday’s report of an outbreak in Kisana, the Ministry of Health (MOH) has dispatched Dr. Daidan, Surveillance Officer and IHR National Focal Point, to the region. Dr. Daidan visited the Kisana Health Center and spoke with medical personnel and some patients about the outbreak. From his preliminary informal investigation, it appears that the majority of patients are suffering from diarrheal disease after attending a large feast held in the village a week ago to celebrate the Chinese New Year. However, patients seem more severely ill than would be expected from a food-borne illness, and mortality has been high, especially among young children and older adults. Dr. Daidan has implemented a plan for nurses to administer a questionnaire to patients and collect fecal samples from all patients with diarrhea (respiratory samples are already collected through ILI surveillance). There are also a number of patients seeking care for influenza-like illness with complaints of fever (>38°C) and cough. Dr. Daidan also provided additional information on the three patients hospitalized at Central General Hospital. Two patients have been suffering from fever (>38°C) and diarrhea since 2 and 3 February, respectively, and were both admitted on 5 February with severe dehydration. Both patients are stable as they continue receiving intravenous rehydration. The third patient has different symptoms. He has complained of fever (>38°C) and diarrhea, but also cough and sore throat, since 4 February and was admitted on account of continued fever and cough with difficulty breathing on 6 February. The patient was enrolled in SARI surveillance at admission, but his condition has deteriorated quickly and he is currently in the intensive care unit. All three patients attended the new year’s celebration in Kisana; in fact, the SARI patient was the main cook for the event. The Ministry of Agriculture and Livestock is investigating claims of sick pigs in Kisana. Regards, Sara Yu WHO Liaison Officer – Domina - 38 - THIS IS AN EXERCISE MESSAGE CONTROLLER'S COMMENTS: - 39 - EVENT INJECT FORM EVENT ID SCHED TIME INJECT MEANS CONTROLLER I19 12:20 Email PRIORITY DESCRIPTION OF EVENT MOH reports a problem with H7N9 testing protocol Actual inject time: Exercise time: 15 March FROM: WHO liaison officer INFO: TO: All SUBJECT ASSISTANCE REQUESTED FOR H7N9 TESTING THIS IS AN EXERCISE MESSAGE Dear WHO, The Central National Laboratory has reported that it is having a problem with the new H7N9 testing protocol. They have samples from two SARI patients at Central General Hospital that have given positive results for H7 but negative results for N9. They have rerun both samples three times and received the same results each time. Laboratory technicians are concerned that primers and probes for these diagnostics may have been damaged during a recent power outage during which the generator failed to start. It is not known how long reagents were without appropriate temperature control. We are very concerned that we will have another case of avian influenza A(H7N9) and request assistance from WHO or from the WHO CC to resolve this issue, helping us to understand whether the problem is related to the reagents or to the protocol. Please do not hesitate to contact us should you need any further information to make these arrangements. Regards, Dr. Daidan IHR National Focal Point Ministry of Health – Domina THIS IS AN EXERCISE MESSAGE CONTROLLER'S COMMENTS: - 40 - EVENT INJECT FORM EVENT ID SCHED TIME INJECT MEANS CONTROLLER I21 12:40 Email PRIORITY DESCRIPTION OF EVENT Four additional ILI and one additional SARI cases Actual inject time: Exercise time: 18 March FROM: WHO liaison officer INFO: TO: Surveillance team SUBJECT FOUR ILI AND ONE SARI CASES, LABORATORY RESULTS THIS IS AN EXERCISE MESSAGE Dear WPRO, One additional SARI case has been reported: 62-9380, a 52 year old woman from Kisana, developed fever (>38°C), cough and sore throat on 16 March and was hospitalized 17 March. She is a neighbor of 79-3392. Four additional ILI cases have been reported in Domina: 61-9203 is a 53 year old woman who is married to 60-2295. She sought care yesterday afternoon after waking up with fever (>38°C), cough and sore throat yesterday morning. 52-6649, a 62 year old shop owner sought care yesterday for fever (>38°C) and cough. He reported that his symptoms began on 17 March, a day after his business partner became ill with similar symptoms. 68-8332 is a 46 year old woman from Domina who works as a seamstress and often shops at the store owned by 52-6649. She sought care yesterday afternoon after waking up with fever (>38°C) and cough yesterday morning. 06-1962 is an 8 year old girl who is classmates with 05-2990. She was brought to the outpatient clinic yesterday by her mother, who reported that she had been wheezing since early that morning and had fever (>38°C) and sore throat. A new batch of laboratory results are attached. Regards, Sara Yu WHO Liaison Officer – Domina ATTACHMENT National ID # 78-9374 Age 36 - 41 - Sex Female Region Kisana Requested by Central General Hospital Case category ILI Sample Quality Test Methods Results Nasal swab (<0.4ml) On ice RT-PCR: Flu A Flu B H1 (seasonal) H1 (pandemic) H3 H5 H7 H7N9 Detected Not detected Not detected Detected Not detected Not detected Not detected Not detected ATTACHMENT National ID # 90-8339 Age 24 Sex Male Region Kisana Requested by Central General Hospital Case category ILI Sample Quality Test Methods Results Nasal swab (<0.4ml) On ice RT-PCR: Flu A Flu B H1 (seasonal) H1 (pandemic) H3 H5 H7 H7N9 Detected Not detected Not detected Not detected Not detected Not detected Not detected Not detected ATTACHMENT National ID # 89-2348 Age 25 Sex Male Region Kisana Requested by Central General Hospital Case category ILI Sample Quality Test Methods Results Nasal swab (<0.4ml) On ice RT-PCR: Flu A Flu B H1 (seasonal) H1 (pandemic) H3 H5 H7 Detected Not detected Not detected Not detected Not detected Not detected Detected - 42 - H7N9 Not detected ATTACHMENT National ID # 00-2874 Age 14 Sex Male Region Kisana Requested by Central General Hospital Case category ILI Sample Quality Test Methods Results Nasal swab (<0.4ml) On ice RT-PCR: Flu A Flu B H1 (seasonal) H1 (pandemic) H3 H5 H7 H7N9 Detected Not detected Not detected Not detected Not detected Not detected Not detected Not detected ATTACHMENT National ID # 82-1911 Age 32 Sex Female Region Domina Requested by Central General Hospital Case category ILI Sample Quality Test Methods Results Nasal swab (<0.4ml) On ice RT-PCR: Flu A Flu B H1 (seasonal) H1 (pandemic) H3 H5 H7 H7N9 Detected Not detected Not detected Not detected Not detected Not detected Detected Not detected ATTACHMENT National ID # 02-9831 Age 12 Sex Male Region Kisana Requested by Central General Hospital Case category ILI - 43 - Sample Quality Test Methods Results Nasal swab (<0.4ml) On ice RT-PCR: Flu A Flu B H1 (seasonal) H1 (pandemic) H3 H5 H7 H7N9 Detected Not detected Not detected Not detected Not detected Not detected Detected Not detected ATTACHMENT National ID # 84-9923 Age 30 Sex Female Region Domina Requested by Central General Hospital Case category ILI Sample Quality Test Methods Results Nasal swab (<0.4ml) On ice RT-PCR: Flu A Flu B H1 (seasonal) H1 (pandemic) H3 H5 H7 H7N9 Detected Not detected Not detected Not detected Not detected Not detected Detected Not detected ATTACHMENT National ID # 05-2990 Age 9 Sex Female Region Domina Requested by Central General Hospital Case category ILI Sample Quality Test Methods Results Nasal swab (<0.4ml) On ice RT-PCR: Flu A Flu B H1 (seasonal) H1 (pandemic) H3 H5 H7 H7N9 Not detected Not detected Not detected Not detected Not detected Not detected Not detected Not detected - 44 - ATTACHMENT National ID # 60-2295 Age 54 Sex Male Region Domina Requested by Central General Hospital Case category ILI Sample Quality Test Methods Results Nasal swab (<0.4ml) On ice RT-PCR: Flu A Flu B H1 (seasonal) H1 (pandemic) H3 H5 H7 H7N9 Detected Not detected Not detected Not detected Not detected Not detected Detected Not detected CONTROLLER'S COMMENTS: - 45 - EVENT INJECT FORM EVENT ID SCHED TIME INJECT MEANS CONTROLLER I28 12:00 Email PRIORITY DESCRIPTION OF EVENT International media report widely on new virus in Kisana Actual inject time: Exercise time: 22 March FROM: International media INFO: TO: All SUBJECT INTERNATIONAL MEDIA REPORTS ON NEW VIRUS - 46 - THIS IS AN EXERCISE MESSAGE Original source: http://www.bbc.co.uk/news/health-26020015 - 47 - Original source: http://sinosphere.blogs.nytimes.com/2014/02/05/scientists-warn-of-danger-of-new-bird-flu-strain-in- china/?_php=true&_type=blogs&_r=0, http://www.aljazeera.com/video/asia-pacific/2014/01/s-korea-alert-after-avian-flu-outbreak- 20141271721220514.html - 48 - Original source: http://edition.cnn.com/2014/02/12/opinion/kerry-sebelius-health-security/index.html?iref=allsearch THIS IS AN EXERCISE MESSAGE CONTROLLER'S COMMENTS: PANSTOP 2014 Participants' Handbook - 49 - ANNEX 6 PARTICIPANTS’ HANDBOOK PANSTOP 2014 PANDEMIC PREPAREDNESS RAPID CONTAINMENT EXERCISE February 18 and 19, 2014 PARTICIPANTS' HANDBOOK A pandemic preparedness rapid containment exercise conducted by the World Health Organization PANSTOP 2014 Participants' Handbook - 50 - Introduction Exercise Panstop 2014 is an exercise designed to strengthen the processes required to initiate a rapid containment (RC) operation with the intention of stopping or slowing the spread of a potentially pandemic influenza outbreak. The exercise will be held in the WHO Regional Emergency Operations Center. The exercise will be based around a scenario of a disease outbreak in a fictional country, with consequent opportunities to contain the outbreak by utilizing stockpiles of antiviral medication and non-pharmaceutical interventions. The focus will be mainly on WHO RO and CO planning and decision-making processes during a routine rapid response and through launching an RC operation. This handbook provides exercise participants (players, controllers, evaluators) with the information they will need to participate effectively in the exercise. Participants are encouraged to ask questions concerning their roles and responsibilities and the rules of exercise play in advance to Exercise Director (panstopcontrol@wpro.who.int) Purpose, Scope and Objectives Purpose The purpose of the exercise is to assess the preparedness of DSE to evaluate the need for and initiate a RC operation with the intention of stopping or slowing the spread of a potential pandemic influenza virus. Scope • The exercise will be a modified functional exercise: • The exercise will be based on a fictional scenario • It will be interactive, requiring participants to respond to each other in the roles designated for them in their duty statements, • It will be conducted under time constraints that will be similar to, or even more challenging, than a real event; • No actual movement of human or physical resources will be required • Exercise players will be required to work from their designated operations centre or regular work environment and should be guided by their existing plans and procedures where appropriate The exercise will last for two 4-hour blocks (Tues and Wed morning) and will be controlled by the input of messages and requests for information by exercise management. Objectives 1. To assess capacity to initiate and conduct timely risk assessments 2. To assess process of EOC activation in harmony with ERF 3. To validate established decision-making processes for initiation of RC PANSTOP 2014 Participants' Handbook - 51 - 4. To practice development and implementation of risk communications 5. To ensure understanding of procedures for mobilization ASEF stockpiles; and 6. To verify established coordination and communication arrangements between WHO and JICS Participants and Locations The exercise will include WHO Western Pacific Regional Office (WPRO) and a representative from JICS. The entire exercise will take place in the EOC. Exercise Conduct Day 1 (Tues Feb 18) – exercise will begin immediately following the morning meeting through 1pm in the WPRO EOC (403). Day 2 (Wed Feb 19) – exercise will begin immediately following the morning meeting through 1pm in the WPRO EOC (403). During the last 30 minutes of day two there will be a post-exercise debriefing and evaluation session. The exercise may end before end earlier each day if the exercise director determines that all objectives and performance criteria (anticipated actions) have been sufficiently addressed and that evaluators can complete their assessments. Following the exercise, all players are requested to submit their documentation (action logs, problem logs and evaluation sheets) by 4 pm Feb 19. Exercise Assumptions The following assumptions have been made in order to ensure that the exercise is as realistic as possible. It is intended that exercise events progress in a logical and realistic manner and that all exercise objectives be achieved during the exercise play. 1. Exercise players are knowledgeable about organization response plans and procedures and their assigned roles and responsibilities within them. 2. Controllers and simulators will use simulated (artificial) data and information support sources. 3. Players will respond in accordance with existing procedures, plans, and policies. In the absence of appropriate written instructions, players should use their own initiative to satisfy response requirements. All actions should be recorded in an action log (Annex). Exercise Artificialities Players will encounter a few artificialities and constraints that result from the simulated scenario. Exercise players should accept these artificialities as they are necessary to achieve exercise objectives. PANSTOP 2014 Participants' Handbook - 52 -
The exercise will be played in compressed time. Over the 8 hour period of exercise, the events in the scenario will depict several days of simulated activity. This will have an effect on the amount of time allowed for decision making and is accounted for in the evaluation process.
Because of the limited time available in which to conduct the exercise, 'time jumps' will occur. This means that the exercise elapsed time between consecutive events may represent several hours or even days. At various times exercise time will slow to allow for ore time for discussion ad decision making. Exercise controllers will ensure that all players are aware of changes in exercise time.
Responses obtained by players from simulations (both verbal and written) may not be of the quality or detail available from the real organization or individual. • During the exercise, some actions may normally require deployment of personnel or resources; however, no live movement of personnel or material is required. Exercise Simulation Simulation (artificial representations of reality) will occur during the exercise to compensate for non- participating individuals or organizations including WHO HQs, relevant government authorizations, external organizations, citizens of the community, and others. Safety and Security Given the nature of this exercise, there is no anticipated personnel safety or security issues of concern. Emergency Suspension/Termination The Exercise Director may unilaterally suspend play or end the exercise at any time when it appears that a real-world emergency may hamper exercise play or jeopardize the safety of exercise participants. If required, the Exercise Director will announce the decision to suspend or terminate exercise play and an “EMERGENCY EXERCISE SUSPENSION/TERMINATION” message will be transmitted to all participants. Exercise Management Team Roles and Responsibilities The exercise will be managed by an Exercise Director and controlled by an exercise simulation team. The primary responsibility of the exercise management team is to monitor, manage, and control exercise activity to achieve the stated objectives PLEASE DO NOT FIGHT THE SCENARIO!! ALL MESSAGES (VERBAL, E-MAIL) MUST INCLUDE THE WORDS "THIS IS AN EXERCISE MESSAGE" AT THE BEGINNING AND END OF THE COMMUNICATION!! PANSTOP 2014 Participants' Handbook - 53 - Players • React and respond as you would during a real event • Explain actions and decisions to other players, simulators, evaluators, as required • Document all actions that would be taken, challenges and problems • Be creative but realistic went planning and responding to the events • Be aware that simulators represent all resources and agencies that you would contact in a real situation • Participate in Exercise debriefings and provide a written evaluation • Submit action logs, problem logs and evaluation sheet by 4pm Tues • Ensure all Exercise correspondence is clearly marked “This is an EXERCISE message” or “EXERCISE PANSTOP 2014” Controller (Erica) • Overall responsibility for the planning, conduct and evaluation of the exercise. • Monitor and control sequence of events, flow, pace of injects and overall conduct of the exercise. • Make decisions regarding unanticipated actions or resource requirements made by players. • Assist players, providing advice and guidance as necessary. Simulators (Ailan, CK, Katherine) • Send pre-scripted messages at specific time and in special sequence to proper player. • Respond to players requests by simulating the various roles, agencies and resources that are required. • Respond creatively to anticipated actions by players with spontaneous messages • Report any deviations or exercise problems and concerns to the Controller. • Participate in exercise briefings and debriefing. • Provide a written evaluation. • Ensure all exercise correspondence is clearly marked “EXERCISE” or “EXERCISE PANSTOP 2014”. Evaluators (Ms. Ochiai, Katherine) • Observe whether the exercise objectives are achieved. • Evaluate the actions and decisions of the players, not the players themselves. • Inform controller on any problems arising during the exercise. • Participate in exercise debriefings. • Provide verbal and written feedback of observations and recommendations made during the exercise. Communications PANSTOP 2014 Participants' Handbook - 54 - Players must be available in their designated location with their own email inbox open on Feb 18 and 19 from 09:00 to 13:00. Not all players will be active during the entire exercise as the initial scenario and subsequent events require a staged response, requiring more communication and coordination as the events unfold. Players, Controller and Simulators should use the PANSTOP 2014 contact list for communication. All messages or questions to organizations or people that are not in the contact list should be sent to panstopcontrol@wpro.who.int . panstop@wpro.who.int will receive all injects to WPRO. Players in WPRO can monitor and confirm all mail communications through this mail box. All e-mail exchanges should be copied to panstopcontrol@wpro.who.int. This is a simulator/control mail box. ALL messages MUST BE MARKED “This is an EXERCISE message”. Reporting Players are requested to record all significant activities and actions taken an exercise log sheet (Annex) and submit it at the end of the exercise. A record keeper should be appointed for this purpose. Completed documentation, action logs/reports, notes from meetings and TCs, etc. should also be submitted to Panstop Exercise Control (panstopcontrol@wpro.who.int) at end of exercise. All participants should use the Problem Log (Annex) to record problems encountered during the exercise, particularly those that reveal potential weaknesses in the response to a pandemic threat. All participants are requested to attend the after action debriefing session at the close of exercise play on day 2 and complete a written evaluation sheet (Annex). The information from participants’ feed back (both verbal and written), will form the basis for the Panstop 2014 Evaluation Report. Annexes 1. Players' Action Log 2. Problem Log PANSTOP 2014 Participants' Handbook - 55 - Annex 1: Players’ Action Log Name ________________ Position ____________ Agency _________________ Page __ of ___ Time/Date Activity Issue/Information Requested Referred to/Resolution Call to/Received From *Log must be sent to by e-mail to panstop@wpro.who.int by 16:00, 19 February 2014. PANSTOP 2014 Participants' Handbook - 56 - PANSTOP 2014 Participants' Handbook - 57 - Annex 2: Problem Log Date: _____________ Exercise Assignment: (circle) Player, Controller, Simulator, Evaluator, Director, Observer Time Message No. (if known) Problem Analysis (Leave Blank)*2 *Log must be sent to by e-mail to panstop@wpro.who.int by 16:00, 19 February 2014. - 58 - - 59 - ANNEX 7 EVALUATION FORM Please answer each on a scale of 1 (not very well) to 5 (extremely well): 1. I understand my normal role in a: _____ rapid response operation (day 1) _____ rapid containment operation (day 2) 2. This PANSTOP exercise helped me practice and understand more fully my role in _____ rapid response operation (day 1) _____ rapid containment operation (day 2) 3. This PANSTOP exercise helped me practice and understand more fully others role in _____ rapid response operation (day 1) _____ rapid containment operation (day 2) 4. Following this exercise I better understand logistics necessary to support _____ rapid response operation (day 1) _____ rapid containment operation (day 2) 5. I feel I need additional information/training in (please circle all that apply) a. Risk assessments b. EOC operations c. ERF as it relates to DSE d. Criteria for activation of stockpiles e. None of the above f. Other (please describe) - 60 - For PANSTOP 2014, please describe any g. Strengths h. Recommendations for improvement in PANSTOP 2015 6. Regarding general EOC operations, please describe a. Strengths b. Areas for improvement