Napa Foodborne Illness Tabletop Exercise 2013


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

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  • 205 cases in 26 states.Cattle are considered the primary reservoir of E. coli O157, but fecal shedding by other domestic livestock and wildlife has been described.The outbreak was amplified because the contaminated spinach from one or a few farms was mixed with spinach from numerous other farms, then bagged by a few processors, marketed under several brands, and distributed nationally and internationally.
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  • CEIP is alerted when any foodborne outbreak is identified. They help to coordinate foodborne outbreak response in Bay Area counties (Alameda, Contra Costa, San Francisco) alongside CDPH
  • The time from when a patient eats contaminated food to the when the public health lab completes confirmatory testing and fingerprinting A series of events occurs between the time a patient is infected and the time public health officials can determine that the patient is part of an outbreak. This means that there will be a delay between when a person gets sick and confirmation that he or she is part of an outbreak. Public health officials work hard to speed up the process as much as possible. The timeline is as follows:Incubation time: The time from eating the contaminated food to the beginning of symptoms. For E. coli O157, this is typically 3-4 days.Time to sample collection: The time from the first symptom until the person seeks medical care, when a diarrhea sample is collected for laboratory testing. This is typically 1-5 days.Time to diagnosis: The time from when a person gives a stool sample to when E. coli O157 is obtained from it in a laboratory. This may be 1-3 days from the time the sample is received in the laboratory. The diagnosis of E. coli infection may be reported to the local health department at this time.E. coli isolate shipping time: The time required to ship the E. coli O157 bacteria from the laboratory to the state public health authorities that will perform “DNA fingerprinting.” This may take 0-7 days depending on transportation arrangements within a state and the distance between the clinical laboratory and public health department.Time to serotyping and “DNA fingerprinting”: The time required for the state public health authorities to perform “DNA fingerprinting” on the E. coli O157 isolate and compare it with the pattern of the outbreak strain. Ideally, this can be accomplished in 1 day. However, many public health laboratories have limited staff and space, and experience multiple emergencies at the same time. Thus, the process may take 1-4 days.The time from the beginning of a person’s illness to the confirmation that he or she was part of an outbreak is typically about 2-3 weeks
  • Further discussion: CMS waivers, L&C waivers (Nursing staff ratios, Surge tents, etc.) CAL OSHA guidance, State Declarations and Gubernatorial Declarations
  • Napa Foodborne Illness Tabletop Exercise 2013

    1. 1. Napa County 2013 Medical Health Tabletop Exercise October 28, 2013 10:00 AM – 2:00 PM 1
    2. 2. Welcome and Introductions The 2013 Statewide Medical and Health Exercise is sponsored by: • California Emergency Medical Services Authority • California Department of Public Health In collaboration with: • • • • • California Hospital Association California Association of Health Facilities California Primary Care Association California Emergency Management Response partners representing local health departments, emergency medical services, public safety and healthcare facilities 2
    3. 3. Welcome and Introductions  Introduction of Exercise Planners and Facilitators  Housekeeping Issues  Agenda Review 3
    4. 4. Exercise Purpose To evaluate current response concepts, plans, and capabilities related to a medical surge of patients from a foodborne illness outbreak in the local community. The exercise will focus on the coordination of surveillance activities and health system capabilities anticipated when managing a medical surge among community healthcare partners. 4
    5. 5. Exercise Target Capabilities  Public Health Epidemiology & Surveillance  Emergency Public Information & Communications  Emergency Operations Center Management & Medical Surge 5
    6. 6. Tabletop Exercise Objectives Evaluate ability to:  Activate surge plans  Implement the Incident Command System  Request, distribute, track and return resources in accordance with the California Public Health Emergency Operations Manual (EOM)  Coordinate risk communication 6
    7. 7. Tabletop Exercise Objectives Evaluate ability to:  Issue public information notifications  Conduct surveillance and epidemiological investigations  Implement necessary control measures to stop further cases of illness or disease 7
    8. 8. Tabletop Exercise Scenario Scenario:  Napa residents are presenting to healthcare providers with abdominal pain and bloody diarrhea in above average numbers  Some patients are needing hospital and ICU admission  A foodborne disease is suspected 8
    9. 9. Subject Matter Experts • Dr. Jennifer Henn, Epidemiologist • Napa County Public Health • Dr. Karen Smith, Health Officer • Napa County Public Health • Jahniah McGill, Registered Environmental Health Specialist • Environmental Health, Napa County 9
    10. 10. EPIDEMIOLOGY Dr. Jennifer Henn Epidemiologist Napa County Public Health 10
    12. 12. FOODBORNE ILLNESSES • Caused by ingestion of contaminated food • Can also be spread via other modes • Gastrointestinal tract symptoms  Nausea & vomiting  Diarrhea  Abdominal pain • Nonspecific symptoms outside the G.I. tract • Children under 5, older adults and medically fragile are most vulnerable 12 12
    13. 13. FOODBORNE ILLNESSES An estimated 1 in 6 suffer from foodborne illnesses annually leading to an estimated:  48 million cases  128,000 hospitalizations  3,000 deaths  $35 billion in medical costs & lost productivity >1,000 outbreaks detected annually (Painter JA, Hoekstra RM, Ayers T, Tauxe RV, Braden CR, Angulo FJ, et al. Attribution of foodborne illnesses, hospitalizations, and deaths to food commodities by using outbreak data, United States, 1998– 2008. Emerg Infect Dis [Internet]. 2013.) 13 13
    14. 14. DAILY DOUBLE What foodborne disease do these foods have in common? • • • • • • Raw sprouts Pizza Cookie dough Fresh spinach Ground beef patties Romaine lettuce 14 14 14
    16. 16. E. COLI O157:H7  First recognized as pathogen in 1982  First outbreak traced to hamburgers  USDA banned sale of raw meat containing E. coli O157:H7 in 1994  Many outbreaks now linked to contaminated raw vegetables (e.g., sprouts, leafy greens) and other contaminated ready to eat foods 16
    17. 17. STEC OUTBREAKS 2012 Multistate Outbreak of Shiga Toxin-producing Escherichia coli O157:H7 Infections Linked to Organic Spinach and Spring Mix Blend Multistate Outbreak of Shiga Toxin-producing Escherichia coli O145 Infections Source not identified Multistate Outbreak of Shiga toxin-producing Escherichia coli O26 Infections Linked to Raw Clover Sprouts at Jimmy John's Restaurants 17
    18. 18. STEC OUTBREAKS 2011 Multistate Outbreak of E. coli O157:H7 Infections Linked to Romaine Lettuce Outbreak of Shiga toxin-producing E. coli O104 (STEC O104:H4) Infections Associated with Travel to Germany (and consumption of raw sprouts) Multistate Outbreak of E. coli O157:H7 Infections Associated with Lebanon Bologna Multistate Outbreak of E. coli O157:H7 Infections Associated with In-shell Hazelnuts 18
    19. 19. E. COLI CONTAMINATION AN EXAMPLE  Multistate E. coli O157:H7 outbreak linked to baby spinach in 2006 (205 cases, 102 hospitalizations, 3 deaths)  Outbreak strain isolated from both cattle and feral swine feces near spinach field  Spinach from 1 field with E. coli contamination mixed with spinach and lettuce from other farms at central processing plants 19
    20. 20. CONTAMINATION AN EXAMPLE Feral pigs had access to both cattle and spinach fields Surface water used for irrigation potentially contaminated with E. coli 20
    21. 21. E. COLI AND MEDICAL SURGE AN EXAMPLE  Outbreak of E. coli O104:H4 in 2011 – 3,816 cases in Germany; 54 deaths – 845 (22%) involved Hemolytic Uremic Syndrome (HUS)  Hospitals in most affected areas of Germany experienced large influx of patients with HUS and other complications due to E. coli infection – Doubled number of staff – Tripled machines for dialysis and plasma exchange 21
    22. 22. E. COLI AND MEDICAL SURGE AN EXAMPLE Video news clip: 22
    23. 23. SHIGA TOXIN PRODUCING E. COLI  Common reservoirs = cattle and other ruminants  Vehicles in past outbreaks = ground beef, petting zoos, raw vegetables and fruit, unpasteurized apple cider, water, etc.  Growth requirements = facultative anaerobe, nonsporulating bacterium 23
    24. 24. E. COLI - EPIDEMIOLOGY  Mode of Transmission  Ingestion of food contaminated by traces of feces or direct contact with animals and their environment  Incubation Period  Range from 2-10 days after exposure; median 3-4 days  Period of Communicability  When the bacteria is being excreted  1 week or less (adults) or up to 3 weeks (children) 24 24
    25. 25. SHIGA TOXIN PRODUCING E. COLI (STEC)  Some E. coli bacteria produce shiga toxin  When shiga toxin enters the bloodstream it can damage the red blood cells  Severity of illness ranges from mild diarrhea to life threatening HUS 25 25
    26. 26. CLINICAL SYMPTOMS AND TREATMENT OF STEC INFECTIONS Dr. Karen Smith Health Officer Napa County Public Health 26
    27. 27. SYMPTOMS Symptoms of E. coli infection:  Watery and often bloody diarrhea  Abdominal cramping  Abdominal pain  Little or no fever Most people will recover within 5 to 10 days 27
    28. 28. HEMOLYTIC UREMIC SYNDROME (HUS)  Life threatening condition that often requires ICU treatment  Triad of hemolytic anemia, thrombocytopenia, and acute renal failure  Often requires blood transfusions and dialysis during acute phase 28
    29. 29. HEMOLYTIC UREMIC SYNDROME (HUS)  On average, HUS occurs in ~6% of E. coli patients  Case fatality rate of 3-5%  Most cases of HUS occur in children under 5  Use of antibiotics and anti-diarrheal medication to treat E. coli infection increases risk of HUS 29
    30. 30. DIALYSIS  Average length of dialysis for patients with HUS due to E. coli infection is 5-7 days (but can vary widely)  Peritoneal dialysis widely used for pediatric patients  Hemodialysis also suitable for children - may be preferable in patients with severe abdominal pain 30
    31. 31. MANAGEMENT OF HUS Successful management of HUS includes: • Fluid therapy • Management of acute renal failure - ~50% of HUS patients require dialysis • Blood and/or plasma transfusion - Most children require packed RBC transfusion • Management of hypertension • Nutritional support and pain management 31
    32. 32. STEC – SPECIAL CONSIDERATIONS  Most E. coli related HUS cases seen in children < 5, but elderly and immunocompromised are also at increased risk for HUS  Elderly patients at higher risk for E. coli blood stream infection (bacteremia) and may develop additional complications due to presence of other illnesses 32
    33. 33. FOODBORNE OUTBREAK RESPONSE Dr. Jennifer Henn Epidemiologist Napa County Public Health 33
    34. 34. OUTBREAK INVESTIGATION GOALS  Identify all cases  Find a common exposure  Determine cause  Stop the exposure  Prevent future cases  Notify providers  Inform the public 34 34
    35. 35. A COORDINATED RESPONSE Public Health Foodborne Illness Response Team Laboratory Environmental 35 Health 35
    36. 36. PUBLIC HEALTH RESPONSE ROLE Public Health Nurses and Disease Investigators • Interview patients • Collect clinical specimens from patients • Administer questionnaires for epidemiologic studies • Advise patients on how to prevent spread of illness • Provide public health education & guidance (i.e., health advisories and health alerts) 36 36
    37. 37. PUBLIC HEALTH RESPONSE ROLE Epidemiologists • Analyze data from pathogen-specific surveillance and identify clusters/outbreaks • Characterize cases by time, place, and person • Plan epidemiologic studies • Interview cases and healthy controls • Analyze and interprets results of epidemiologic studies 37
    38. 38. PUBLIC HEALTH LABORATORY RESPONSE ROLE Public Health Laboratory staff • Analyze clinical, food, and environmental specimens • Interpret test results and “fingerprint” strains • Advise about tests and collection, handling, storage, and transport of specimens • Coordinate additional testing by partner labs 38
    39. 39. WHO ARE THE PUBLIC HEALTH STATE AND FEDERAL PARTNERS? • California Emerging Infections Program (CEIP) • California Department of Public Health (CDPH) • Centers for Disease Control and Prevention (CDC) 39 39
    41. 41. ENVIRONMENTAL HEALTH RESPONSE Jahniah McGill, MPH Registered Environmental Health Specialist Napa County Environmental Health 41
    42. 42. HOW DOES ENVIRONMENTAL HEALTH BECOME AWARE OF FOOD RELATED EVENTS? Environmental Health • Reporting Methods − − Online complaint system Telephone complaint • Reporters of Illness − − − Consumer complaints Food facility operators Health and Human Services: Public Health • State & Federal Partners − − − California Food & Drug Branch (CDPH) US Food and Drug Administration (FDA) US Department of Agriculture (USDA) 42 42
    43. 43. ENVIRONMENTAL HEALTH RESPONSE ROLE Environmental Health Inspectors focus on how the food became contaminated: • Receive and interpret foodborne illness complaints • Investigate suspected food and/or food establishment − Interview food workers and managers − Examine food storage, handling, preparation, and service − Identify risk factors that resulted in food contamination − Collect environmental and food samples − Collect paperwork 43 43
    44. 44. ENVIRONMENTAL HEALTH RESPONSE ROLE Environmental Health Inspectors focus on how the food became contaminated: Implement control measures • Employee education • Disposal of contaminated food • Impound • Closure of premises • Administrative hearing process • Probationary period 44 44
    45. 45. ENVIRONMENTAL HEALTH RESPONSE ROLE Environmental Health Inspectors refer to the following agencies: • CDPH Food and Drug Branch (CDPH) − Manufacturers, Processors, Wholesale − Seafood and Shellfish − Recall of Foods • CA Department of Food and Agriculture (CDFA) − All Meat and Dairy Products • U.S. Food and Drug Administration (FDA) − Interstate Manufactures, Processors, Wholesale 45 45
    46. 46. HOW DO YOU CONTACT ENVIRONMENTAL HEALTH? PBES: Environmental Health Division Main Phone: (707) 253-4471 or (707) 253-4417 Main E-mail: County Website: 46 46
    47. 47. Exercise Ground Rules  Do not fight the scenario  Assume the scenario is real and may impact the jurisdiction and the participants  Participate in a collegial manner: share policies, plans and practices that may benefit others 47
    48. 48. Exercise Ground Rules  Be respectful: allow others to speak and finish their statements  Follow communications etiquette: turn off cell phones, computers, and any other electronic data equipment 48
    49. 49. Tabletop Exercise  The exercise consists of three modules plus an addendum for planning the November 21, 2013 Functional Exercise  Each module will identify the key issues followed by questions for discussion  Participants are encouraged to share their plans, policies, strengths and gaps as identified in the Organizational Self Assessments 49
    50. 50. Scenario On November 18, 2013, healthcare providers at community health centers, private physician’s offices and local emergency departments began seeing previously healthy patients with complaints of abdominal pain throughout Napa County. 50
    51. 51. Scenario (Continued) Within one day, 40 cases of bloody diarrhea had been reported by 10 healthcare providers at community health centers, private physician’s offices and local emergency departments in the county. Two days after the first reports of abdominal pain and bloody diarrhea, 4 patients (of which, 2 are pediatric) were admitted to the Intensive Care Unit with symptoms of decreased urine output, lethargy and persistent bloody diarrhea. These patients were diagnosed with hemolytic uremic syndrome. Cases presenting similar symptoms continue to be reported throughout the county. 51
    52. 52. Scenario (Continued) Five days after the first reported case, 225 patients (approximately 10% with HUS) have been identified with similar presenting symptoms at local hospitals, community health centers and private physician practices. 52
    53. 53. Scenario (Continued) Healthcare facility staff has requested guidance from the local Public Health Laboratory on appropriate protocols for specimen collection and laboratory techniques to confirm the diagnosis. Healthcare facilities are requesting guidance on necessary levels of isolation and personal protective equipment requirements for staff. 53
    54. 54. Module 1: Public Health Surveillance and Epidemiological Investigation Key Issues:  Surveillance and epidemiological investigation coordinated with the healthcare partners  Implement control measures 54
    55. 55. Questions for Discussion 1. When and how would your organization/agency be made aware of an increase in Shiga Toxin-producing E. coli isolates within your jurisdiction? a. Are there multiple modes of communication for this kind of information? 2. What would prompt an investigation, and who would undertake the investigation and analysis if an outbreak were to occur in your jurisdiction? 55
    56. 56. Questions for Discussion 3. How does your organization/agency collaborate with the laboratories? a. How is testing prioritized? 4. How are control measures issued by Public Health, Environmental Health, healthcare facilities? a. How are the control measures implemented by each? 56
    57. 57. LUNCH BREAK 57
    58. 58. Module 2: Emergency Public Information and Communications Key Issues:  Alerting and notification of personnel  Internal and external communications  Risk communication messaging 58
    59. 59. Questions for Discussion 1. What mechanisms and/or technologies are in place to alert and notify your staff of activation of your facility’s emergency operations plan? a. How do you notify staff of activation? b. Who is responsible to do that? c. How often do you test this system? d. Has this system been used in a real event? e. Who else do you notify of activation? f. How does that occur? 59
    60. 60. Questions for Discussion 2. How do you share information with Public Health? a. What information do you share? b. What information do you expect from Public Health? c. How do you communicate your facility status (and bed availability) to the local medical health system? d. How does this information get to the state? 60
    61. 61. Questions for Discussion 3. What is your risk communication plan to notify staff, patients, clients and/or stakeholders of a foodborne illness outbreak? a. Who approves the information to be shared? b. What communication methods are used? c. How does your organization participate in a Joint Information System (JIS)? d. What would warrant opening a Joint Information Center (JIC)? e. How do you manage inquiries from the media, stakeholders, and the general public? 61
    62. 62. Scenario (Continued) Ambulance companies are reporting an increase in call volume and extended delays in offloading patients at local emergency departments. Hospitals are experiencing continuing surge with increasing emergency department wait times. The initial epidemiologic investigation has not revealed a consistent pattern of age, race, occupation, geographic distribution or previous symptomatology among patients which might indicate a source of the offending agent. 62
    63. 63. Module 3: Emergency Operations Center Management and Medical Surge Key Issues:  Response is coordinated through the use of Incident Command System principles and Command Centers/Emergency Operations Centers  Incident Action Plans are developed to guide and document the response and recovery phases  Activation of Surge Plans  Request and/or response to resource requests 63
    64. 64. Questions for Discussion 1. How do you plan for an influx of patients including the access and functional needs population? a. What types of services can be altered, postponed or relocated to other sites? b. Have clinical providers been active in the decision making for alteration of services? 64
    65. 65. Questions for Discussion 2. Which partner organizations can assist in providing services that you must alter or suspend due to a medical surge? a. Do you have Memoranda of Understanding signed with these partner organizations? 3. How do you request, respond to, distribute, track and/or return resources in accordance with the California Public Health and Medical Emergency Operations Manual? 65
    66. 66. Resource Requesting Dr. Karen Smith Napa County Public Health Officer 66
    67. 67. Medical & Public Health Resources • Personnel • Services • Supplies and Equipment • Transportation • Facilities 68
    68. 68. Healthcare Facility Managers How to Obtain Resources: • Communication through accepted local protocols • Communicating resource arrangements minimized duplication of efforts 69
    69. 69. HC Facility Resource Utilization • Determine if current resources will meet the anticipated needs • Prioritize/conserve what’s available • Contact suppliers/contractors • Implement existing agreements • Request help from the HHSA/DOC - MHOAC 70
    70. 70. HHSA Department Operations Center (DOC) DOC Director PIO Health Officer Safety Officer Liaison Officer Operations Section Planning Section Logistics Section Finance Section Medical Branch Health Branch 72
    71. 71. DOC Medical & Health Branch Operations Section Medical Branch Health Branch EMS/Transport Patient Tracking Communicable Disease Healthcare Facilities Coordination Laboratory Alternate Care Site Activate branches as needed Mass Prophylaxis 73
    72. 72. CA Mutual Aid System • CA disaster & Civil Defense Master Mutual Aid Agreement (MAA) • Discipline-Specific Mutual Aid Agreements • Health Care Facilities Mutual Aid or Mutual Assistance Agreements 75
    73. 73. CA Mutual Aid Regions 3 1 2 4 5 6 1 76
    74. 74. Regional Disaster Medical & Health Coordinator/Specialist (RDMC/S) REOC Medical Health Branch RDMHC/S Program OA EOC Med. Health Branch MHOAC Program OA EOC Med. Health Branch MHOAC Program OA EOC Med. Health Branch MHOAC Program Affected Local Jurisdictions 77
    75. 75. Who You Gonna Call? Public Health/ HHSA!!! Public Health/HHSA DOC is your gateway to CA’s mutual aid… 79
    76. 76. Tabletop Conclusion You Survived! 80
    77. 77. HOT WASH 81
    78. 78. Planning for the November Functional Exercise The scenario will be a medical surge due to foodborne illness. Customization of the exercise allows incorporating other objectives as needed. Examples include issues identified in past exercises, new training or equipment, or new policies and procedures. 82
    79. 79. November Exercise Issues for Consideration Exercise Level of Play:  What level of exercise play do the organizations/agencies represented today anticipate for the November 21, 2013 exercise?  Examples include communications drill, functional and full scale exercises, level of play may include use of simulated patients, movement of patients to healthcare facilities, activation of the joint information center, provision of mutual aid, etc.  Will your organization/agency activate its Command Center/Emergency Operations Center? 83
    80. 80. Role of State Agencies On November 21, 2013, the California Department of Public Health and the California Emergency Medical Services Authority will open the Medical and Health Coordination Center (Formerly the Joint Emergency Operations Center). The California Emergency Management Agency is anticipated to participate by opening the State Operations Center and the Regional Emergency Operations Centers to support local and regional exercise play. This will provide the opportunity for local participants to request additional resources, submit and receive situation status reports and respond to California Health Alert Network (or other notification systems) messages and receive further direction. 84
    81. 81. Evaluations Please complete your Evaluation… 85
    82. 82. Thank You For Your Participation Additional materials may be found on: California Statewide Medical and Health Training and Exercise Program website: 86