Transcript Statewide Exercise Training for Partners

2013 Statewide Medical &
Health Exercise –
Healthcare Partners Training
Scenario: Foodborne Illness Outbreak
1
Welcome Healthcare Partners
to the 2013 Medical and Health
Disaster Exercise Training and Tabletop
Who’s your
partner?
Introductions
Disaster Response Overview
Jan Koegler, MPH
PHD Emergency Preparedness Administrator
3
Partners in Disaster Response

Disaster Healthcare Partners Coalition


Sets priorities for disaster planning for healthcare
and long-term care
Plans how healthcare providers will work
together during a disaster or other incident which:


Limits resources or
Requires a healthcare surge for increased numbers of
patients
4
“The last place I want to meet
you for the first time is during
a disaster.”
Agenda



Housekeeping Issues
Agenda Review
Handouts Review
6
Santa Barbara County
Medical and Health Disaster Exercises
Date
2012
2011
2010
2013 FOODBORNE
OUTBREAK
Scenario
Earthquake
Water Emergency
Improvised Explosive Device
2009
Pandemic Influenza (Actual Event)
2008
Pandemic Influenza
2007
Bomb
2006
Bioterrorism and Receive, Store, and Stage Plan
2005
Chemical Plume
2004
DOC/EOC Activation
2003
Plague
Scenario



Large foodborne outbreak causes illness in
multiple healthcare, long term care,
universities and residents across California.
The foodborne pathogen (the type of bacteria)
causing the illness is identified by laboratories
as E. coli (Escherichia coli)
The food causing the outbreak is being
investigated by local and state health depts
Training and Tabletop Objectives



Partners will receive training in how local
and state public health departments respond
to foodborne illness outbreaks
Partners and PHD will practice the use of
line lists, food interview questionnaires, and
data reporting on status forms for disease
outbreaks (tabletop exercise)
Partners will recognize their role,
responsibilities, and the communication
channels with PHD during a disease outbreak
9
Training and Tabletop Objectives




Partners and PHD will prepare to use status
report forms during the statewide exercise
Partners will draft prioritized objectives for
response to a foodborne outbreak
Partners will provide input on the best way to
validate and coordinate risk communication
during the exercise and disaster operations
Discuss plans for continuing operations when
staff is affected by the outbreak
10
Exercise Participants


Healthcare Partners (SNF, LTC, outpatient,
hospitals) in Santa Barbara County
Santa Barbara Public Health Department




Environmental Health Services
Santa Barbara Emergency Medical Services
Agency
California Department of Public Health
California Emergency Medical Services
Agency
11
Role of State Agencies in Exercise

State will open the Medical and Health
Coordination Center
California Department of Public Health and Emergency Medical Services Authority

State Operations Center and the Regional
Emergency Operations Centers
California Emergency Management Agency

County will communicate to State:

Make request to region for additional resources

Submit situation status reports to State

Respond to CAHAN alerts from the State
12
Disaster Operations in Our County
COUNTY EMERGENCY
OPERATIONS CENTER
County Fire
Department
Operation
Center
City of Santa
Maria
City of Santa
Barbara
Sheriff’s
Department
Operation
Center
City of
Guadalupe
City of Lompoc
Public Health
Department
Operation
Center
City of Buellton
City of Solvang
City of Goleta
City of
Carpinteria
Public Works
Department
Operations
Center
Relationship of Healthcare and Long Term Care to their Cities and the PHD
COUNTY EOC
JOINT INFORMTATION
CENTER “JIC”
PUBLIC HEALTH
DEPARTMENT/EMS
CITY EOC
Public Information
Hospital Open? ED Open?
Where should patients go for care?
Public Information
Hospital Open? ED Open?
Where should patients go for care?
Healthcare or
Long Term Care
Facility or Agency
PUBLIC HEALTH
DEPARTMENT OPERATIONS CENTER
MHOAC
Operations Section is a hub for
communication with partners for status and resource requests
Role of
Medical and Health
Operational Area Coordinator
“MHOAC”
Status Report and
Requests from
Medical and Health
during disaster
MHOAC
Healthcare, long term care,
animal services,
environmental health, EMS
HOW TO CONTACT “MHOAC” (PUBLIC HEALTH/EMSA)
PHD Disaster Operation Plan
Infectious Disease Emergency Response Plan
Foodborne and
other infectious
diseases
19
Organizational Chart
20
Introduction to Foodborne Illness

Michelle Wehmer, MPH
PHD Epidemiologist
21
What is an Foodborne Illness (FBI)
Outbreak?


Two or more cases of similar illness from
separate households from a common food
source OR
One or more cases of illness from food
confirmed or suspected to be contaminated
with botulism, marine toxins, or other
chemicals
22
SM Times—Norovirus
23
CDC Estimates of Foodborne Illness
in the U.S. (2011)
CDC-- impact of foodborne illness U.S.:
 1 in 6 gets sick (48 million)
 128,000 are hospitalized
 3,000 die
25
CDC Estimates of Foodborne Illness
in the U.S. (2011)
http://www.cdc.gov/foodborneburden/2011-foodborne-estimates.html
26
CDC Estimates of Foodborne Illness
in the U.S. (2011)
27
Source of Outbreaks…..
28
Implicated Issues
29
Who is most vulnerable?
According to CDC FoodNet data tracking:
 Children younger than 5 years old have higher
incidence rates of Salmonella,
Campylobacter, Shigella, Cryptosporidium,
E.coli O157 and E.coli non–O157 infection.
 Adults 60 and older at greatest risk for
hospitalization and death from infections.
30
SB PHD—Enteric Disease Stats
Enteric Disease Counts - Santa Barbara County, 2007-2012.
120
100
60
Counts
80
40
20
0
Campylobacteriosis
Salmonellosis
Giardiasis
Shigellosis
Hepatitis A
2007
84
46
29
16
5
2008
84
49
32
17
5
2009
99
42
25
17
8
2010
85
51
22
11
0
2011
102
51
24
6
3
2012
109
48
25
19
1
Source: CalREDIE - Santa Barbara PHD. 2013
31
SB PHD—Outbreak Stats
2009 2010 2011 2012
Total Number of Outbreaks
(OBs) Investigated
18
16
21
20
# of Entericrelated OBs
16
12
12
15
# of FBI OBs
0
2
2
1
32
Foodborne Illness Investigation Goals
1. Determine if an outbreak has occurred
2. Identify the pathogen (bacteria, protazoa,
virus, helminthes, chemical?)
3. Identify Vehicle of Transmission (Food is
contaminated? Sick food worker?)
4. Control the outbreak
33
1. Determine if an Outbreak has
Occurred…



Two or more people are ill
They have similar symptoms
They have eaten common food items
34
A large outbreak in one place may be
obvious.
35
An outbreak with cases dispersed in many
places may be difficult to detect, unless…
 We test the pathogens from all the cases, and
 We find they are infected with the same exact bacterial strain
36
How to find an outbreak…..
37
2. Identify the Pathogen




Obtain clinical specimens from ill persons
Obtain samples of suspect foods, if possible
Obtain swabs of food contact surfaces
Determine most likely pathogens to help
focus the investigation
38
Making the Connection….





PulseNet: A national network of public health and
food regulatory laboratories coordinated by the
CDC
California Public Health Department lab participates
Performs molecular subtyping – “DNA
fingerprinting” of foodborne disease-causing
bacteria
Shares results with the CDC electronically
PulseNet database users can identify DNA-identical
pathogens across the US which could be linked to
commercially distributed food
39
3. Identify Vehicle of Transmission





Identify ill food handlers or other workers,
past or present
Interview ill consumers
Identify improper food handling procedures
Identify potential food source
Conduct epidemiological
analysis
40
Investigation Tools



Epidemiology Unit provides
initial investigation
recommendations
Interview questionnaires
created
Collected information
analyzed
41
4. Controlling the OUTBREAK
Paige Batson, RN, PHN, MA
PHD Disease Control Manager
42
Control the Outbreak





Examine clinical specimens from food
handlers, other workers or consumers
Exclude or Restrict certain workers (SOS)
Inspect Food Facilities (Violations/Corrections)
Impound or Destroy suspected foods
Disciplinary Action (Close restaurants or food
businesses)
43
Reporting Disease
1.
2.
Who should report?
What diseases are legally reportable by
employers or health care providers?
3.
4.
When should they be reported?
How should they be reported?
44
Title 17: Reportable Diseases & Conditions
45
Ill Staff Reported
46
Public Complaints
2.
Disease Reporting
(Continued)
Electronic Reporting:
CalREDIE
47
Controlling Disease Outbreaks: Public
Health Department Role


Investigate and Interview Ill Persons
Legally Restrict or Exclude Individuals in
sensitive occupations/situations:


Restaurant, healthcare, childcare
Collect and test stool samples from workers
to:


Determine if they have foodborne illness
Determine if they can return to work
48
Restriction/Exclusion Grid
49
Notice of Exclusion/Restriction Sensitive Occupation
(employer)
50
Notice of Exclusion/Restriction (employer)
51
Environment Health Services (EHS)


Kathy Cardiel, EHS Supervisor
Jennifer Bernstein, EHS Supervisor
52
What does EHS do?








Restaurant Inspections
Water Quality Program
Temporary Food Facility Permits
Public Swimming Facilities Inspections
Liquid Waste Program
Hazardous Materials Unit
Housing Safety
Recalls
53
EHS Responsibilities in an Outbreak





Takes calls from the public who believe they are
ill from eating at a restaurant
Lead for reports of possible food-related illness
Two or more calls from the same establishments
Notifies Disease Control (DC) for Suspected
Outbreak
Partners with State for tracing commercially
contaminated food sources
54
What does EHS inspect for during a
possible outbreak?






Cooking & food holding temperatures
Food handling practices
Names of employees on duty during exposure
Number of meals served
Collects food/environmental samples (COC)
Suspect foods and trace-back
55
E: PHL Chart for Food/Clinical Specimens
56
Campylobacter Outbreak—Food Facility
57
Campylobacter OB—Food Facility
58
Campylobacter OB—Food Facility
59
Campylobacter OB—Food Facility
60
Campylobacter OB—Food Facility
61
Campylobacter OB—Food Facility
62
How are clinical and food samples
tested?
EXAMPLE: E. Coli





Clinical samples: sent to commercial labs and Santa
Barbara Public Health Lab
Food samples: sent to Public Health Lab
Commercial labs can detect Shiga toxins
SB PHL can determine the serotype
State PHL will determine DNA typing and send to
PulseNet for registration in nationwide database
63
BREAK
• Victims
Get Your
Cards
64
Escherichia Coli ….
“E Coli”
•
Gram-negative, anaerobic, rod-shaped bacterium
common in lower intestine of warm-blooded
organisms
•
Harmless strains are part of normal flora of the gut
and prevent other harmful bacteria from growing in
the intestine
•
Some serotypes cause serious food poisoning in
humans, occasionally responsible for product recalls
due to food contamination
65
Transmission of E. Coli



Undercooked ground meet, raw milk, fruits and
vegetables where contamination may be due to feces
from domestic or wild animals at some stage during
cultivation or handling
Person-to-person contact is an important mode of
transmission through the oral-fecal route
Asymptomatic carrier state reported, individuals show
no clinical signs of disease but are capable of infecting
others (up to one week)
http://www.who.int/mediacentre/factsheets/fs125/en
/
66
PETTING ZOOS
67
Virulent Strains of Shiga Toxin producing
E. coli “STEC” or “EHEC”

Incubation usually 3-4 days after the exposure





Diarrhea (often bloody), abdominal cramps
Little or no fever (less than 101 degrees Fahrenheit)
Vomiting (less common)
5%-10% develop hemolytic uremic syndrome (22% in
the German outbreak 0104/H4)


May be as short as 1 day or as long as 10 days
50% of HUS survivors have chronic renal disease
Children and the elderly at greatest risk
68
Treatment



Rest and supportive therapy including
hydration
No evidence that antibiotics are helpful. Can
increase risk of hemolytic uremic syndrome
Antidiarrheal agents may also increase risk of
HUS
69
E. Coli Outbreak:
Europe in 2011: 3,950 Shiga Toxin-producing 0104:H4
E. coli infections linked to fenugreek sprout seeds
Difficult to determine food source

53 deaths (51 in Germany)

852 confirmed cases of hemolytic uremic
syndrome (HUS) a type of kidney failure

Cases were reported in Germany,
Switzerland, Poland, the Netherlands,
Sweden, Denmark, UK, Canada and the USA
http://www.cdc.gov/ecoli/2011/ecoliO104/index.html European Food Safety Authority
70
Destroying Suspect Spanish Cucumbers 2011
By Daily Mail Reporter 9 June 2011
“Spanish cucumbers were initially blamed, then ruled out
after tests showed they had a different strain of E.coli.
On Sunday, investigators pointed the finger at German bean
sprouts, only to backtrack a day later when tests came back
negative. The sprouts are to have further tests.”
71
Identifying the food source…..
Der Spiegel, June 14, 2011:
A spokesman for the Federal Institute for Risk
Assessment (BfR) said that a total of 9,000 food
samples had been tested across Germany since
the outbreak in early May, focusing on
cucumbers, tomatoes, lettuce and beansprouts.
http://www.spiegel.de/international/germany/death-toll-reaches-37-two-yearold-boy-dies-in-german-e-coli-outbreak-a-768278.html
72
High incidence of Hemolytic Uremic Syndrome
“Around 300 more cases have been reported, bringing
the number to 2,648. Almost 700 of these people were
suffering from a serious complication that can cause
kidney failure.”
http://www.dailymail.co.uk/news/article-2000965/Deadly-E-coli-outbreak-peaked-saysGerman-health-minister.html#ixzz2hp5rvHH5
73
Impact of Outbreaks…. United States
Multistate Outbreak of Shiga Toxinproducing E. coli 0157:H7:
A total of 33 persons infected with Shiga Toxin producing
E. coli were reported from five states
 46% of ill persons were hospitalized.
 Two ill persons developed hemolytic uremic syndrome
(HUS), no deaths
 Traceback investigations of pre-packaged leafy greens
purchased by ill persons
http://www.cdc.gov/ecoli/2012/O157H7-11-12/index.html
74
Public
Information:
Media, Public
75
Public Information:
Media, Public

Instruction to the public is critical to assure:





Protection of the public’s health
Appropriate use of limited healthcare resources
Respond to public outcry for answers
High profile events that involve commercial
industries, jobs and income
Press may go to hospitals and clinics, call
UCSB, or skilled nursing facilities
76
During Exercise on November 21:



PHD will hold a teleconference with partners
to share information, templates, and
coordinate media response
PHD will hold a teleconference to share
medical and epidemiologic information and
strategize on surge plan to provide care
Discuss and strategize on how your agency
would establish hotlines for your patients and
their families
77
TABLETOP TRAINING





Administering a Food Survey Questionnaire
Compiling a Line List
Completing a Status Report Form
Completing a Resource Request Form
What are your Questions for PHD (real event
OR exercise)
78
Line Lists and Food Surveys
Which facilities will be asked to complete a line
list or food survey during an outbreak?
 Hospitals, SNF, residential facilities
What will outpatient providers be asked to report?
 Suspect or confirmed patients via CalREDIE
 Surge of suspect or confirmed patients daily
Hospitals
 Complete daily ReddiNet outbreak poll for ED
surge, bed capacity, etc.
79
Example: Foodborne Questionnaire
80
Criteria for Face-to-face Interviews





Good interpersonal skills
Independent Workers
Reliability
In certain circumstances, parallel
demographic characteristics
among interviewers and
interviewees
Safety
81
Getting Ready to Interview

Practice reading the questionnaire out loud




Do you understand what the questions are asking?
Are there any foreseeable questions that might arise?
Do you know how to code the answers?
Ensure confidentiality
82
Interviewing Procedures





Read questions as worded
Probe inadequate answers if necessary
Record answers as respondent answers
Maintain rapport with respondents
Maintain an even pace
83
Probing versus Leading
Example:
Interviewer: In the last 7 days, how many times did you eat
prepared food at the school cafeteria?
Would you say:
a. None
d. 3 times
b. Once
e. More than 3 times
c. Twice
Respondent:
“Oh, gee, I didn’t go very often… maybe a few times.”
84
Probing versus Leading
Example:
Interviewer Probe (correct)
“Which would be closer: none, once, twice, 3 times, or more
than 3 times?”
Interviewer Leading (incorrect)
a.
“So, would you say twice or 3 times?”
b.
“Do you mean twice or 3 times?”
85
Data Collection

Creating a line list from questionnaires




Identifying information
Demographic information
Clinical information
Risk factor information
86
Example Line List
Example line listing – Acute Hepatitis A*
Signs/Symptoms
Case #
Report
Date
Labs
Demographics
Onset
Physician
Diagnosis
N
V
A
F
D
J
HAIgM
Other
Sex
Age
1
10/12/2002
10/5/2002
Hep A
Y
Y
Y
Y
Y
Y
Y
Low SGOT
M
37
2
10/12/2002
10/4/2002
Hep A
Y
N
Y
Y
Y
Y
Y
Low Alt
M
62
3
10/13/2002
10/4/2002
Hep A
Y
N
Y
Y
Y
Y
Y
Low SGOT
M
38
4
10/13/2002
10/9/2002
NA
N
N
Y
N
?
N
NA
NA
F
44
5
10/15/2002
Hep A
Y
Y
Y
Y
Y
N
Y
Hbs/Ag-
M
17
6
10/17/2002
Hep A
N
N
Y
Y
Y
Y
Y
SGOT=24
F
43
10/6/2002
* N=nausea, V=vomiting, A=elevated aminotransferase, F=fever, D=discreet
onset, J=jaundice, HAIgM=hep AIgM antibody test
SGOT=serum glutamic oxaloacetic transaminase ALT=alanine aminotransferase
Hbs=hepatitis B surface antigen, Ag-=antigen negative, Y=yes, N=no
87
Scenario
On October 20, 2013, health care providers at
community health centers, private physician’s offices
and local emergency departments began seeing
previously healthy patients with complaints of
abdominal pain throughout Santa Barbara County.
88
Scenario (Continued)



By October 21st 25 cases of bloody diarrhea had
been reported by skilled nursing facilities,
outpatient providers, and emergency departments
October 22nd clinical labs report positive shiga
toxin producing E. coli
On October 23rd 4 patients were admitted to the
Intensive Care Unit with symptoms of decreased
urine output, lethargy and persistent bloody
diarrhea.
89
Scenario (Continued)
October 22
 Due to the need to investigate
large numbers of suspect cases
the PHD activates its Infectious
Disease Emergency Response
Plan
 SNF, hospitals, and long term
care facilities are instructed to
submit a line list of ill
patients/residents and to
conduct interviews using food
questionnaires
90
Healthcare Surge: E. Coli Outbreak
http://www.spiegel.de/international/germany/farmers-losing-millions-eu-officials-take-aim-at-germany-for-ecoli-approach-a-767087.html (excerpt below)
…. hospitals association said members were overwhelmed with
the financial strain of the outbreak, and demanded government
aid. "In light of the E. coli epidemic I appeal to politicians to take
back the financial cuts planned for hospitals," ..
The situation proves just how important keeping beds and staff
available at clinics can be, he said, explaining that healthcare
institutions in affected areas …managed to stay afloat because
they were swapping staff.
"The clinics are doing everything necessary for the care of the
sick -- without considering whether their services will be
compensated by health insurers later,"
91
Tabletop Instructions






Victims Take a Seat
Interviewers Bring Your Forms
When interview is complete victims should
work on their facility/agency status reports
SNF/Hospital/LTC group compile line list and
then move on to status report
Report Back! List resource requests on board
Questions and Suggestions for real events or
exercise
92
Thank You for Participating!
93
Report Back and Wrap Up




Questions for PHD regarding food interview
or line lists
Questions re using the status forms
Exercise questions?
Questions for your facility to use during the
exercise will be provided



How will your organization surge to meet the increased needs of patients?
Who makes the decision to extend hours? How quickly can decisions be made?
With a surge of inpatients, where would they receive dialysis?
94
Foodborne Outbreak Org Chart
Disease Control Manager
EHS Director/Supervisor
Deputy HO
Health Officer
POLICY GROUP
OPERATIONS SECTION CHIEF
(Disease Control & Prevention Manager)
Functional Incident Commander when DOC unopened
Environmental Health
Branch
Public Health Branch
Laboratory Group
(Laboratory
Director)
Lab Testing
Team
Lab
Documentation Team
Lab Surge
Team
Surveillance Group
(Epidemiology
Manager)
Surveillance
Team
Members
Investigation Group
(DC SPHN)
Case/Contact
Investigation
Team Leader
Environmental
Health Services
(EHS Supervisor)
EHS Staff
Field Team
Members
95
Participating in 2013
Foodborne Disaster Exercise
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Participate in exercise teleconferences
Complete participation form and send to PHD in advance
Review your plan and train your staff
Participate in training on October 22 or 24
Participate in exercise on November 21th
Use the Exercise Instruction Form
Submit a Status Report Form with Your Objectives
Submit a Resource Request Form
Ask PHD for guidance on how to control spread of disease
or treat patients
SNF/LTC/Hospital Inpatient: Complete a line list
SNF/LTC: Use foodborne survey
Evaluate your participation. Write an improvement plan.
Foodborne Outbreak Org Chart
Disease Control Manager
EHS Director/Supervisor
Deputy HO
Health Officer
POLICY GROUP
OPERATIONS SECTION CHIEF
(Disease Control & Prevention Manager)
Functional Incident Commander when DOC unopened
Environmental Health
Branch
Public Health Branch
Laboratory Group
(Laboratory
Director)
Lab Testing
Team
Lab
Documentation Team
Lab Surge
Team
Surveillance Group
(Epidemiology
Manager)
Surveillance
Team
Members
Investigation Group
(DC SPHN)
Case/Contact
Investigation
Team Leader
Environmental
Health Services
(EHS Supervisor)
EHS Staff
Field Team
Members
97
E. Coli Outbreak: 2011 Germany
Hospitals…report working at their limits to treat patients
suffering from a rare strain of the bacteria… never before seen by
scientists in an outbreak.
Aggressive mutant strain… caused severe complications onethird of patients, who have developed hemolytic-uremic
syndrome...
Doctors are scrambling to provide kidney dialysis for these
patients, reportedly rushing them between cities in ambulances
because only a limited number of machines are available.
Meanwhile hospital workers are said to be giving up weekends
and vacation to meet growing demand. Fears of blood bank
shortages have also sparked calls for citizens to donate their
98
blood.