Assignment:
Case Study
Bioterrorist Attack on Food: A Tabletop Exercise
This exercise, developed by the Northwest Center for Public Health Practice,* is designed as an opportunity for public health personnel and their local emergency counterparts to gain skills and knowledge in preparing for and responding to a large-scale communicable disease event. Participants address a hypothetical bioterrorism incident in the form of an infectious disease outbreak to acquire this learning. The exercise enables participants to identify the communication, resources, data, coordination, and organizational elements associated with an emergency response. Discussion questions are embedded in the scenario as it unfolds.
LEARNING OBJECTIVES
Through review and discussion of this tabletop exercise, students will be able to:
• Understand measures that can be performed at the local level to prepare for a large-scale communicable disease or bioterrorism incident.
• Promote interagency collaboration/coordination regarding emergency preparation and responsiveness.
• Recognize the roles of a variety of public officials in a large-scale communicable disease or bioterrorism incident.
• Recognize the need for intense teamwork and communication to prepare for a large-scale communicable disease or bioterrorism incident.
• Identify gaps in local preparedness and ability to coordinate.
• Identify additional related training/learning needs (an assessment tool).
INTRODUCTION
This exercise is aimed at identifying the policy questions that must be considered in responding to a bioterrorism event. The depicted exercise scenario will enable participants to understand and experience the shortcomings or gaps in their ability to identify and respond to policy issues (as opposed to operational procedures). Participants will be required to state policy questions such as these: Who should be responsible? Or what information is needed? Or when is public information given out? In essence, participants will be identifying what is required in responding to an incident and not necessarily how an agency will actually respond. It is important that the exercise identify policies required to respond effectively to the scenario rather than using only those policies that currently exist. Addressing those policies that need clarification or development will be helpful in eventually strengthening the overall response system and will identify areas in operational policies and procedures that need refinement.
PART 1
Storyboard 1
This incident affects four counties: Cedar, Dogwood, Pine, and Maple. The incident begins in Cedar County in the month of August.
Cedar County
• Total population: 150,000 residents.
• The major city, Watertown, has a population of 40,000 residents.
• There are two area hospitals; one is a children's hospital.
• There are numerous nursing homes and day care centers.
• International trade, tourism, agricultural products, and lumbering are the major industries.
• An economic trade group conference is scheduled to be held in Watertown in 3 weeks. About 100 members will be attending, including foreign economic officials.
• Residents are all served by a regional public water supply system.
• The Cedar County health department has a staff of 70 employees. The department has a full-time director of public health and a full-time health officer (MD). A full range of public health services, including environmental health, community health nursing, laboratory, and clinical public health services, are provided.
Dogwood County
• Located directly to the north of Cedar County.
• Total population: 35,000 residents.
• Noted for its numerous water recreational areas.
• About 10,000 residents are served by small or individual water supply systems.
• The Dogwood County health department has 25 total staff, including environmental health specialists and community health nurses. A health officer (MD) is part time.
Pine County
• Located directly to the south of Cedar County.
• Total population: 15,000 residents.
• Serves as a bedroom community to Cedar County. Many Pine County residents commute to work in Cedar County's major city.
• Residents receive public water supplied by Cedar County Regional Water Utility.
• The Pine County health department has a total of 14 staff members (5 are part time). Two are environmental health specialists and 10 are public health nurses. The remaining staff members provide administrative support. A health officer is a contract physician from the community.
The state health department is located in Maple County, 140 miles to the east of Cedar County. The state health department's public health laboratory and the state's university are also located in Maple County. The population of Maple County is 1 million.
Event 1
Day 1, Friday
Persons with gastrointestinal illness are beginning to contact their medical care providers through the nurse hotline and patient consultation lines. Individuals with gastrointestinal problems are calling or visiting area emergency rooms and urgent care centers on Friday afternoon and evening. The hospital's patient consultation line is experiencing an increased number of callers with symptoms including severe diarrhea, fever, chills, headache, nausea, vomiting, abdominal pain, and possibly bloody stools. All cases describe diarrhea as a symptom. Almost all report at least two or more of the additional symptoms. Illnesses have lasted 1 to 2 days without improvement. Most patients are middle-aged adults, but approximately 10% are over the age of 65. A total of 30 people are seen in hospital emergency rooms and urgent care centers by late Friday evening. (This means that a total of 400 individuals may be exhibiting similar symptoms but are not seeking medical care. The 30 cases, or 7.5% of the 400, visit a medical care provider for symptoms.) Stool samples are taken for six of the affected cases seen by a physician. Three individuals are hospitalized for dehydration or other gastrointestinal complications.
Day 2, Saturday Morning
Patients are still being seen in the emergency room and urgent care centers. By 10:00 a.m., the number of patients exhibiting similar symptoms is up to 45. The decision is made to notify the health department. There is some concern about the capacity of the clinics to handle the increasing number of patients seeking treatment.
Questions for you to consider and discuss as if you were part of the emergency preparedness response team follow. Please do not skip ahead in the story, but follow the events in the sequence they are presented here.
1. How do medical care providers decide when to contact health officials?
2. How do medical care personnel determine whom to contact?
3. How is the health department person contacted (after hours/non-business days)?
4. What does the health department do with this information? What additional information does the health department need? How does the medical care facility address its capacity needs?
Event 2
Day 2, Saturday Noon
By noon, the patient count is up to 60. The local health officer decides to convene a meeting to discuss next steps. A local pharmacist calls the local hospital to ask what is happening. The pharmacist reports that the store is almost out of antidiarrheal medicine because of heavy demand.
Questions for you to consider and discuss as if you were part of the emergency preparedness response team follow. Please do not skip ahead in the story, but follow the events in the sequence they are presented here.
1. Who should be involved in the meeting?
2. Would nontraditional partners, such as emergency management, be brought in at this time?
3. What should be discussed in the meeting?
4. What is the health department doing to collect additional information about cases?
Event 3
Day 2, Saturday Evening
The health department decides to begin interviewing cases.
Questions for you to consider and discuss as if you were part of the emergency preparedness response team follow. Please do not skip ahead in the story, but follow the events in the sequence they are presented here.
1. How do you proceed?
2. What additional information is needed for further investigation?
Event 4
Day 2, Saturday Evening
Medical care providers from Dogwood and Pine Counties are reporting a high number of patients complaining about severe gastrointestinal problems. By 5:00 p.m., the total patient count from all three counties is 75. Seventeen stool specimens have been taken. Six people have now been hospitalized.
Questions for you to consider and discuss as if you were part of the emergency preparedness response team follow. Please do not skip ahead in the story, but follow the events in the sequence they are presented here.
1. To whom do the medical care providers from Dogwood and Pine Counties report their information, particularly if key health department staff cannot be contacted?
2. How is information being shared between the health agencies?
Event 5
Day 2, Saturday Evening
Hospital personnel have confirmed to the news media a large number of people being seen with some type of "intestinal illness" but refer callers to the health department.
Questions for you to consider and discuss as if you were part of the emergency preparedness response team follow. Please do not skip ahead in the story, but follow the events in the sequence they are presented here.
1. How does the health department respond to the news media inquiries?
2. Does the health department have a designated public information officer?
Event 6
Day 2, Saturday Evening
At 5:00 p.m., a member of a tour group visiting the county reports to the health department that 35 out of 50 members have become ill with severe diarrhea, vomiting, and nausea. None have seen a doctor. All ate at local restaurants in the area for the past week. The group is primarily non-English speaking tourists from Southeast Asia.
Questions for you to consider and discuss as if you were part of the emergency preparedness response team follow. Please do not skip ahead in the story, but follow the events in the sequence they are presented here.
1. Which actions should be taken to respond to this information?
2. How are the issues of language translation handled?
PART 2
Storyboard 2
The focus of attention is being directed toward food service establishments in the three counties as a result of patient interview data. Numerous establishments are being identified as places where interviewed patients have eaten or have purchased foods in the past week.
Many are restaurants; however, specialty grocery stores are also being frequently mentioned.
Twelve identified restaurants are in Cedar County. One is in Dogwood County. All restaurants serve a high volume and variety of customers. They range from well-known, moderately priced, national chain restaurants to popular, high-scale dining establishments. Company executives, business leaders, attorneys, and government officials often eat at the affected city establishments. All are popular with tourists visiting both counties. Four establishments serve ethnic foods. Two are Mexican. The other two are Asian. Three affected restaurants have a history of poor food handling practices, particularly hand washing and temperature violations. None of the establishments have had violations of foods from unapproved sources.
The three specialty grocery stores are highly popular and have a high turnover of food inventory. All are owned and operated by the same company. Two of the specialty stores are in Cedar County. The third is located in Dogwood County. All food service establishments are served by public water but from different water utilities.
Event 7
Day 3, Sunday Morning
Health department personnel interviewing cases are hearing about 12 restaurants being repeatedly named in Cedar County and one in Dogwood County. Three of the restaurants in Cedar County have had a history of food service violations. Several people becoming ill, however, have not eaten at any of the 13 named restaurants. Laboratory results on patients will not be available until the next day.
Questions for you to consider and discuss as if you were part of the emergency preparedness response team follow. Please do not skip ahead in the story, but follow the events in the sequence they are presented here.
1. What is the significance of this information?
2. Which actions are taken on the named restaurants, if any?
3. What information is shared with the news media, if any?
Event 8
Day 3, Sunday Morning
Many ill patients have not eaten at a restaurant in the past week; however, food items being commonly named include fresh salsa, pesto dishes, pizzas, Asian soups, and gourmet salads.
Questions for you to consider and discuss as if you were part of the emergency preparedness response team follow. Please do not skip ahead in the story, but follow the events in the sequence they are presented here.
1. What is the significance of this information?
2. How is this information shared with the public and first responders?
Event 9
Day 3, Sunday Morning
Remember that there is a large economic trade group conference scheduled in Watertown (Cedar County) in 3 weeks, as mentioned in Storyboard 1.
Hospital emergency rooms and medical clinics in the county are becoming overwhelmed with patients. Medical facilities are short staffed because many medical personnel are home ill with "gastrointestinal upset." There is concern among medical staff about spread of the illness within the hospital and the urgent care clinics.
Questions for you to consider and discuss as if you were part of the emergency preparedness response team follow. Please do not skip ahead in the story, but follow the events in the sequence they are presented here.
1. What is the procedure for added capacity to handle the high volume of patients?
2. What is the policy of infection control (and communication) within the medical care facilities?
Event 10
Day 3, Sunday Evening
The patient count is up to 250 after news reports on the disease outbreak. The source is not yet determined, but food is highly suspected, with attention focusing on fresh herbs. Most cases are middle-aged adults. The age range of cases is from 5 to 82 years.
Questions for you to consider and discuss as if you were part of the emergency preparedness response team follow. Please do not skip ahead in the story, but follow the events in the sequence they are presented here.
1. Which actions are being performed by the health department to determine the cause of the outbreak?
2. Which communication systems are in place?
3. Which resources are available to handle an influx of public calls? A phone bank?
4. Which state and national resources are called in?
5. What is the content of the food safety message to the public?
6. How and when does this message get out?
7. Who is dealing with the food industry in the three counties?
Event 11
Day 3, Sunday Evening
Early results of diagnostic tests indicate that Shigella sonnei is the causative agent.
Questions for you to consider and discuss as if you were part of the emergency preparedness response team follow. Please do not skip ahead in the story, but follow the events in the sequence they are presented here.
1. Which actions are needed in response to this result?
Shigellosis Fact Sheet
• Typical symptoms of Shigellosis include severe diarrhea often accompanied by fever, chills, headache, nausea, vomiting, abdominal pain, and possibly bloody stools. The incubation period is 1 to 7 days (usually 1 to 3 days). Fewer than 10% of cases seek medical care, and fewer have confirmatory stool cultures performed. Complications such as dehydration may result in hospitalization, but deaths are rare.
Event 12
Day 3, Sunday Evening
The city's mayor receives a message from an extremist group taking credit for "contaminating the food supply with an infectious bacterial agent." The group threatens to continue to do so unless the upcoming conference of economic trade group representatives is canceled.
The mayor shares the message with the health department director and the chief of police.
Questions for you to consider and discuss as if you were part of the emergency preparedness response team follow. Please do not skip ahead in the story, but follow the events in the sequence they are presented here.
1. How should the health department handle this information?
2. Who should be involved in assessing this message?
3. Who is in charge?
Event 13
Day 3, Sunday Evening
An anonymous person calls the local newspaper and says she represents a group who wishes to take credit for "making people sick with food contaminated with botulism."
Questions for you to consider and discuss as if you were part of the emergency preparedness response team follow. Please do not skip ahead in the story, but follow the events in the sequence they are presented here.
1. What does the health department do with this information?
Events 14 and 15
Day 3, Sunday Evening
The health officer declares a public health emergency. The phone lines are jammed.
Questions for you to consider and discuss as if you were part of the emergency preparedness response team follow. Please do not skip ahead in the story, but follow the events in the sequence they are presented here.
1. Has an emergency operations center already been activated?
2. Where does the health department fit into the emergency operations center's command structure?
Event 16
Day 4, Monday Morning
The reported patient count is now more than 400. Eighty percent of cases are from the largest county. The remaining 20% come from the two adjacent counties. Thirty cases are restaurant workers. Affected cases range in age from 4 to 87 years. Thirty cases are hospitalized. Five are in serious condition.
Questions for you to consider and discuss as if you were part of the emergency preparedness response team follow. Please do not skip ahead in the story, but follow the events in the sequence they are presented here.
1. Which actions are taking place to prevent the outbreak from spreading?
Event 17
Day 4, Monday Morning
The state university microbiology laboratory located in another part of the state reports to the university campus security that numerous vials of Shigella sonnei are missing from the laboratory. The vials were last seen 7 days ago. A few vials from the original batch of the culture are still available. Campus security contacts the county sheriff. The county sheriff contacts its local health department (Maple County).
Questions for you to consider and discuss as if you were part of the emergency preparedness response team follow. Please do not skip ahead in the story, but follow the events in the sequence they are presented here.
1. What does the Maple County health department do after receipt of this information?
2. How is it shared with Cedar County?
PART 3
Storyboard 3
A terrorist group possesses 2 gallons of a liquid broth containing high concentrations of a disease-causing bacterial agent. The cultures of the bacterial agent have been secretly manufactured using stolen vials from a university laboratory. The infectious broth was surreptitiously sprayed onto produce at a food distribution warehouse in Cedar County over a 2-day period. The contaminated produce was then distributed to affected food establishments (13 restaurants and 3 specialty grocery stores): 12 local restaurants and 2 specialty grocery stores in Cedar County and 1 restaurant and a specialty grocery store in Dogwood County. Pine County food establishments were not affected. The produce was used for garnish and seasonings in a variety of dishes at the restaurants. The contaminated dishes were consumed in all 13 restaurants on Tuesday evening and Wednesday lunch and dinner. The produce was also purchased directly by consumers at the three local specialty grocery stores on Tuesday and Wednesday. Residents in all three counties became ill by consuming the contaminated products. Not all sick have visited their medical care provider.
Event 18
Day 4, Monday Evening
Business at area food establishments is dropping significantly.
Questions for you to consider and discuss as if you were part of the emergency preparedness response team follow. Please do not skip ahead in the story, but follow the events in the sequence they are presented here.
1. What is the message to food service operators? To food workers?
2. Who communicates food safety information to the public?
Event 19
Day 4, Monday Evening
News media from other states are calling for interviews or information.
Questions for you to consider and discuss as if you were part of the emergency preparedness response team follow. Please do not skip ahead in the story, but follow the events in the sequence they are presented here.
1. Who responds?
2. How is the response script developed?
Event 20
Day 4, Monday Evening
Re-interviewing of cases and working closely with restaurants to identify common ingredients indicates cilantro and basil as the most likely contaminated products.
Questions for you to consider and discuss as if you were part of the emergency preparedness response team follow. Please do not skip ahead in the story, but follow the events in the sequence they are presented here.
1. What is done with this information?
Event 21
Day 4, Monday Evening
An 86-year-old woman dies from complications resulting from Shigellosis. Her family threatens a lawsuit against the responsible agency.
Questions for you to consider and discuss as if you were part of the emergency preparedness response team follow. Please do not skip ahead in the story, but follow the events in the sequence they are presented here.
1. How are legal issues handled?
Event 22
Day 14, Friday-Recovery Period
Nothing more was ever heard from the extremists. No new infections are attributed to the identified food source; however, secondary cases continue to occur, including outbreaks in 3 day care centers. Public alarm has decreased, but people are still calling about food safety and concerned by the cases that continue to occur-the public does not understand the meaning of "secondary cases." The trade conference is still scheduled for 1 week from today.
Questions for you to consider and discuss as if you were part of the emergency preparedness response team follow.
1. How does the health department ensure the public that the outbreak is over and that the new cases are a result of secondary transmission?
2. Which recommendations should be given to the mayor about the risks of holding the annual conference of trade representatives?
*Northwest Center for Public Health Practice, University of Washington, in conjunction with the Washington State Department of Health.
Originally titled "Hands-on Training for Public Health Emergencies" and developed through funding from the Health Alert Network and the Bioterrorism Preparedness and Response Program at the Centers for Disease Control and Prevention.