Part 1: Exercise Overview

The Mid-America Alliance and the Nebraska Emergency Management Agency (NEMA) participated in an administrative and facilitative role.

Larimer County Department of Health and Environment

Weld County Department of Public Health and Environment

Northeast Colorado Health Department

Kit Carson County Health and Human Services

Lincoln County Public Health

Cheyenne County Public Health

Prowers County Public Health

Kiowa County Nursing Service

Baca County Nursing Service

Cheyenne County Health Department

Hamilton County Health Department

Morton County Health Department

Sherman County Health Department

Stanton County Health Department

Southwest Nebraska Public Health Department

Panhandle Public Health Department

Two Rivers Public Health Department

Albany County Public Health Response Coordinator (Region 3)

Laramie County Public Health (Region 7)

Region 7 Laramie, Goshen and Platte Counties

Union Colony Fire and Rescue Authority

Burlington Fire Protection District

Kansas

Morton County Fire Department

Kit Carson County Emergency Medical Services

Weld County Paramedic Service

Kansas

Stanton County Emergency Medical Services

Morton County Emergency Medical Services

Wyoming

American Medical Response (AMR)

Colorado

High Plains Community Health Center

North Colorado Medical Center

SE Hospital and Long Term Care Center

Sterling Regional Medical Center

Poudre Valley Hospital

McKee Medical Center

Keefe Memorial Hospital

Estes Park Medical Center

Bent County Coroner

Kit Carson County Coroner

Kansas

Morton County Hospital

Stanton County Hospital

Goodland Regional Medical Center

Community Hospital

Tri Valley Hospital

Dundy County Hospital

Perkins County Hospital

Wyoming

Platte County Hospital

Goshen County Hospital

Albany County Hospital

Carbon County Hospital

Cheyenne Regional Hospital (Formerly United Medical Center)

Kit Carson County Communications Center

Prowers County Communications Center

Weld County Communications Center

Stanton County Sheriff Office

WDH Emergency Operations Coordination Center

Burlington Police Department

Kit Carson County Sheriffs Dept

Larimer County Sheriff Office

Stanton County Law Enforcement

Laramie County Sheriffs Dept

Cheyenne Police

Wyoming Highway Patrol

Greeley Emergency Management

Lincoln County Office of Emergency Management

Logan County Office of Emergency Management

City of Loveland Emergency Management

Larimer County Emergency Management

Kit Carson County Office of Emergency Management

Prowers County Office of Emergency Management

Yuma County Office of Emergency Management

Colorado Division of Emergency Management, SE Field Staff

Cheyenne County Emergency Management

Sherman County Emergency Management

Stanton County Emergency Management

Morton County Emergency Management

Hamilton County Emergency Management

Furnas County Emergency Manager

Nebraska Emergency Management Agency

Wyoming

Laramie County Emergency Management (Region 7)

Universities/School Districts

Colorado

University of Northern Colorado

Colorado State University

Nebraska

University of Nebraska

Department of Education

Department of Social Services, ESF 6, SE Region

Kit Carson County Health and Human Services (Social Services Branch)

Larimer County PIO Consortium

Kansas

Southwest Kansas Health Initiative

Morton County Commissioner

Morton County PIO

Nebraska

Wyoming

VA Safety/Security

Laramie County Community College Epidemiology Students

MENTAL HEALTH

Colorado

Centennial Mental Health

Policy and Government

State

Colorado Department of Public Health and Environment

Kansas

Kansas Department of Health and Environment

Nebraska Department of Health and Human Services

Wyoming

Wyoming Department of Health

Office of Homeland Security

Health and Human Services

Department of Transportation

Plains-to-Peak RETAC

Northeast Region Homeland Security

Kansas

Southwest Kansas Regional Homeland Security

South Central Regional LEPC

Evaluators: Evaluators worked as a team with Site Facilitators. They did not interact with players. Evaluators recorded events and ensured documentation was submitted for review and inclusion in the After-Action Report (AAR)/Improvement Plan (IP). Evaluators did not interfere with the integrity of the exercise or players. All questions raised during the exercise were to be addressed by the Site Facilitator.

• 
  Policy issues affecting public health response either positively or negatively on an interstate level
  
• 
  Roles of participating agencies in a Pandemic
  
• 
  Gaps in preparedness and coordination
  
• 
  Identification of related training/learning needs
  

The following were the exercise objectives as outlined in the EXPLAN for this exercise. It should be noted that the format of this EXPLAN is from the Homeland Security Exercise and Evaluation (HSEEP) Toolkit. The objectives in this EXPLAN are formatted in such a way as to suggest an operations based exercise (functional or full-scale). The objectives in the EXPLAN were very ambitious. Typically in a tabletop exercise one would expect to focus on a limited number of objectives, perhaps three to seven.

• 
  In addition to the major goals and objectives listed below it is hoped the following will be discovered:
  
• 
  Policy issues affecting public health response either positively or negatively on an interstate level
  
• 
  Roles of participating agencies in a Pandemic
  
• 
  Gaps in preparedness and coordination
  
• 
  Identification of related training/learning needs
  

1. 
   Results of post-exercise evaluation of the resource directory by border agencies who utilized the directory to communicate information of public health importance with border counties, including information on status of school and public event closures.
   

2. 
   Results of post-exercise evaluation of bordering agencies understanding of key local and bordering agency authorities and stakeholders engaged in pandemic influenza response.
   

1. 
   Local public health agencies will discuss processes for notifying the state following a receipt of a call about an event that may be of urgent public health consequence. Discussion will include the turn-around time for such communication.
   

1. 
   Local agencies will understand and discuss the distribution guidelines as defined by alerts issued through state health alert networks in the exercise.
   
2. 
   Local agencies will discuss the process for seeking appropriate approval and for sharing the information in the alert with the bordering jurisdictions.
   

1. 
   Receive, triage and send case or suspect case disease reports 24/7/365.
   
2. 
   Receive health related data from multiple data sources to monitor, quantify and localize aberrations to normal data patterns
   

1. 
   Local agencies will discuss the process used to define and count confirmed probable or suspect cases and the best means to share information on counts.
   

2. 
   Local agencies will discuss the process used to collect and share reports received on information obtained from multiple data sources including but not limited to veterinary systems, school absenteeism reports, hospital utilization data, nurse call lines and over-the-counter drug sales.
   

1. 
   The criteria for isolation and quarantine
   
2. 
   The procedures and legal authorities for implementing and enforcing these containment measures, and
   
3. 
   The methods that will be used to support, service, and monitor those affected by these containment measures in healthcare facilities, and other settings
   

1. 
   Results of a post-exercise evaluation on each bordering agencies understanding of the procedures and legal authorities for implementing and enforcing containment measures in local jurisdictions and bordering jurisdictions.
   

1. 
   Local agencies will identify the key individual or position responsible for coordinating movement of restrictions to and from jurisdictions.
   

1. 
   Local agencies will discuss process for sharing reports on level of compliance with quarantine orders.
   
2. 
   Local agencies will discuss process for sharing report on school closures and cancellation of events (social distancing).
   

1. 
   Local agencies will discuss nontraditional vehicles of information dissemination that can be used to share information across jurisdictions.
   
2. 
   Local agencies will share knowledge of nontraditional vehicles of information dissemination used within their jurisdiction.
   

1. 
   A four state resource directory outlining resources (forms, specific contact information, multi-agency procedures, etc)
   

1. 
   The communication time to respond to the public and provide honest information.
   
2. 
   Preprinted/ developed communication materials disseminated to all the partners.
   

1. 
   Routine infection control (e.g., hand hygiene, cough/sneeze etiquette)
   
2. 
   Pandemic influenza fundamentals (e.g., signs and symptoms of influenza, modes of transmission)
   
3. 
   Personal and family protection and response strategies (e.g., guidance for the at-home care of ill students and family members)
   

1. 
   The time to issue an isolation or quarantine order
   
2. 
   Time an individual is retained for medical evaluation while determining need for isolation
   
3. 
   Public health officials recommend school closure when pandemic influenza case counts reach pre-determined levels.
   

1. 
   Coordination with response partners and tribal nations
   
2. 
   Rapid provision of public health risk information and recommendations
   
3. 
   Addressing stigmatization, rumors and misperceptions in real time
   
4. 
   Surge capacity for public information, media operations and spokespersons
   
5. 
   Procedures to secure resources to activate the public information and media operation during a public health emergency around the clock if needed for a minimum of 10 days. Prepare supporting materials for public health issues that are unique to an influenza pandemic such as issues of isolation, social distancing, and public health law.
   

1. 
   Time to issue critical health message to the public about an event that may be of urgent public health consequence.
   

1. 
   Develop, exercise and improve operational plans for pandemic influenza at the state and local level. Plans must:
   

1. 
   be compliant with National Incident Management System and include Incident Command System (ICS)
   
2. 
   delineate accountability and responsibility for key local authorities and stakeholders engaged in planning and executing specific components of the operational plan (e.g., identification, isolation, quarantine, movement restriction, healthcare services, emergency care, mutual aid and school closure)
   
3. 
   address integration of state, local, tribal, territorial, and regional plans across jurisdictional boundaries
   

2. 
   Formalize agreements that address communication, mutual aid, and other cross-jurisdictional needs with neighboring domestic and/or international jurisdictions sharing an international border with Canada or Mexico (e.g., city-state-tribal collaboration arrangements or city-state-province/state collaboration arrangements)
   

3. 
   Ensure that legal authorities for executing the operational plan, especially those relevant to case identification, isolation, quarantine, movement restriction, healthcare services, emergency care, and mutual aid, are transparent to all stakeholders
   
4. 
   Identify and communicate to all stakeholders the authority responsible for declaring a public health emergency at the state, local and tribal levels and for officially activating the pandemic influenza response plan
   

• 
  No agency is fully prepared for this type of public health emergency.
  
• 
  Open and honest dialog and feedback are encouraged throughout the exercise.
  
• 
  Participants should feel free to ask questions of one another and challenge each other’s assumptions.
  
• 
  No one will be singled out or punished for what they say during the exercise.
  
• 
  You will act on what you learn
  

1. 
   What are the specific key tasks that public health agencies and their healthcare partners need to carry out to step up surveillance in a way commensurate with the threat?
   

2. 
   What command structure is appropriate at this point, e.g., a formal Incident Command System (ICS), informal ICS, other, or no official structure at this point?
   

• 
  What actions should be taken to engage partners in stepped-up surveillance efforts?
  
• 
  How will any prior planning for surveillance be utilized in this situation?
  
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  What guidance should be provided to healthcare partners regarding their surveillance efforts?
  
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  How will the local public health agency coordinate surveillance and reporting with partners?
  
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  What methods of communication will be used (phone, fax, email etc.)?
  

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  What responsibilities related to surveillance do hospitals and front-line physicians have?
  
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  What expectations do healthcare providers have for public health agencies?
  
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  What type of surveillance should be established in emergency rooms?
  
• 
  What is the role of hospitals and laboratories during stepped-up surveillance efforts?
  

• 
  How would stepped-up surveillance be different from normal influenza-surveillance activities?
  
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  How is information on cases systematically collected and aggregated?
  
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  Who will communicate what information to labs?
  
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  Should anything be done to ensure that existing response systems are working correctly?
  

Probes for if a formal ICS is activated:

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  Who is responsible for activating ICS protocols?
  
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  Who is in charge of the ICS?
  
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  What partner agencies will be involved in the ICS?
  
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  How will the ICS be used to manage the response across partner agencies?
  

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  Is there a defined trigger for when it is appropriate to establish a formal ICS?
  
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  How will all healthcare partners be involved in coordinated decision-making pre-ICS?
  
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  What communication channels will be used across partner agencies?
  

• 
  What partner agency is in charge of coordinating and leading stepped-up surveillance efforts?
  
• 
  What partner agency is responsible for reviewing global, national, regional, and local influenza-activity trends to identify emerging problems?
  

Scenario Part 2

1. 
   Should the command structure you decided on in the previous discussion remain in place, or is a different structure now appropriate?
   
2. 
   What specific key tasks should state agencies engage in to prepare for the outbreak before it reaches Nebraska?
   

Facilitator probes:

Decision 1:

If the command structure will change:

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  What specific changes are appropriate?
  
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  What is different now that requires the change?
  
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  What partner agency is in charge of the new structure?
  

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  Why is no change necessary?
  
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  By what means and how often should partners communicate with one another?
  
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  What will be the “structure” for this communication across state lines?
  

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  What guidance or directives should the public health agency give to healthcare agencies?
  
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  How will the public health agency work with healthcare agencies to manage the “worried well”?
  
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  How will the states coordinate these efforts to speak as one voice?
  
• 
  
  

Probes related to planning for surge capacity:

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  How should agencies coordinate planning?
  
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  What should be done to coordinate the supply of scarce medical supplies?
  
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  What should be done to plan for future needs related to critical infrastructure?
  
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  What can be done to anticipate and limit the number of “worried well”?
  
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  Are partners considering plans to establish nontraditional healthcare facilities?
  
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  What should be done to plan for needs related to staffing at state agencies?
  
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  Is it appropriate to think about recruiting and training volunteers at this time?
  
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  Are there healthcare professionals who could be identified to help in an emergency?
  
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  Are there legal issues (licensing and liability issues, ethical issues, issues related to isolation and quarantine) that need to be addressed before the disease reaches the local area?
  
• 
  How will HHS guidelines for priority groups to receive antiviral drugs be translated into practice?
  

Probes related to disease prevention:

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  What activities should partner agencies engage in related to disease prevention?
  
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  What non-pharmacological approaches to disease prevention are appropriate at this time?
  
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  What should be done to deal with the limited supply of antiviral medications?
  
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  Is it appropriate to begin pre-identifying priority groups for antiviral prophylaxis?
  

1. 
   From each state: Which state agency has primary responsibility for communicating with the media?
   

2. 
   What are the key things that need to be done to ensure proper management of risk communications across partner agencies AND across state lines?
   

3. 
   What are the key messages the public should be told at this point in time?
   

If the public health agency is chosen:

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  What person(s) within the public health agency will be responsible for directly communicating with the media?
  
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  How will the public health agency involve other partner agencies in risk-communication planning?
  

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  Why is public health not the agency responsible for communicating with the media?
  
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  What person(s) will be responsible for communicating directly with the media?
  
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  How will risk-communication messages be coordinated across partner agencies?
  

Probes related to management of risk communication:

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  Should partner agencies wait for the press to contact them, or should they be proactive and schedule regular press conferences?
  
• 
  What channels should be used to get consistent messages out to the public?
  
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  Are there special strategies that need to be considered to communicate with minority groups or special-needs populations?
  
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  How often should partner agencies communicate with the media and in what manner?
  
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  JIC?
  

Probes related to risk-communication messages:

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  What do you anticipate are the questions partner state agencies will most likely need to answer?
  
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  How can risk-communication messages be designed to minimize public anxiety and fear?
  
• 
  What guidance should risk-communication messages contain to try to limit large numbers of worried well from overwhelming the system?
  

Later Developments - Decisions and Responses

1. 
   What key epidemiological steps should be used to follow up with potential cases and their contacts?
   

2. 
   What changes should your agencies be making at this point?
   

Facilitator probes:

Probes for the public health agency:

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  What other information would the public health agencies like to know? For example: Where are the patients now? What tests have been done?
  
• 
  Should the public health agency give any advice to the ICP and the hospital? For example, should public health offer advice about the use of personal protective equipment?
  
• 
  What other infection-control strategies might be necessary at this point?
  
• 
  How would public health staff confirm whether patients were sick with the pandemic flu strain?
  
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  What is the appropriate level of follow-up for each potential case (e.g., chart review, telephone interview, interview in person, contact tracing)?
  
• 
  What samples need to be collected, and who should collect those samples?
  

• 
  How is the clinical information handled and managed?
  
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  How is it collected, aggregated, and shared across partner agencies?
  
• 
  What laboratory or laboratories are appropriate to use?
  
• 
  How are clinical samples packaged and sent to laboratories?
  

Probes for the public health agency:

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  Should any social-distance protocols be implemented at this time?
  
• 
  How will these protocols be enforced and by whom?
  
• 
  Should potential cases and their contacts be quarantined?
  
• 
  What legal authority does the public health agency have to take such steps as closing schools and involuntarily quarantining individuals?
  

• 
  Is antiviral prophylaxis for contacts of patients appropriate at this point?
  
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  How should decisions be made about allocating the scarce supply of antiviral medications?
  
• 
  Who should administer antiviral medications?
  
• 
  What non-pharmacological disease-control strategies should be implemented?
  
• 
  What is the best way to manage scarce medical supplies and staff?
  

It is reported the pair did have a history of travel to Orlando, FL on October 14-16 where they attended an Accredited Respiratory Care Educational Conference. Specimens were being collected for viral testing and being sent to the Kansas State public health laboratory. After further investigation, the public health nurse at Sherman County discovers the staff members were actively involved in promoting the awareness of the new respiratory care program that would be available in 2007 at the college. As part of the promotion, they visited with family members attending the Family Day on October 16 at the college. They were in close contact with family members from 33 Counties who attended the informational session with hands-on activities.

• 
  A global influenza pandemic is confirmed by WHO.
  
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  The outbreak spreads throughout our four-state area with some counties citing early estimates of around 10% of the population falling ill and a 3% case fatality rate. Hospitals and outpatient clinics in the surrounding areas have reached capacity.
  
• 
  
  
• 
  All state agencies across our AREA are reporting staffing shortages. Functioning with only 70% of existing staff.
  
• 
  A significant number of doctors and nurses and other critical infrastructure staff are also unavailable, either because they are ill or have not come to work.
  
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  Staff, who are available to work, report that they are exhausted and need more rest time.
  
• 
  Local pharmacies, health care providers, and hospitals across the AREA are reporting shortages of antivirals as well as diminishing supplies, especially of ventilators, gloves, masks and lab supplies.
  

• 
  What strategies will partner agencies use to manage large staffing shortages?
  
• 
  What essential functions must remain in place for:
  
  • 
    Public health agencies
    
  • 
    Health care partners (especially hospitals)
    
  • 
    Civil society
    
• 
  What strategies will partner agencies use to implement the surge capacity plans outlined earlier?
  

Probes for all partners:

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  How do partners determine how many staff are available without double-counting?
  
• 
  What staff plans are in place to rotate critical staff to avoid complete exhaustion?
  
• 
  How will unmet hospital-staffing needs be addressed?
  

Probes for the public health agency:

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  What public health services must remain in place?
  
• 
  How might public health assist hospitals to maintain their essential functions?
  

• 
  What hospital services must remain in place during the emergency?
  
• 
  Should elective surgeries and other elective procedures be canceled? Who makes these decisions?
  
• 
  What other critical healthcare services must remain in place?
  
• 
  What decisions need to be made about adopting alternative standards of care--for example, shifts in nurse-to-patient ratios?
  

Probes for the public health agency:

• 
  Should Strategic National Stockpile (SNS) or other antiviral stockpiling be implemented?
  
• 
  How is the public health agency working with healthcare facilities and hospitals?
  

• 
  In what ways should hospitals revise their existing triage procedures?
  
• 
  Who makes these decisions?
  

• 
  How are surge-capacity plans coordinated across all partner agencies?
  
• 
  In what way are volunteers utilized, and who is in charge of managing volunteers?
  
• 
  How and where will nontraditional medical sites be established, managed, and staffed to treat patients?
  
• 
  How will people isolated at home receive necessary food and medical supplies?
  
• 
  What partner agency will manage the increasing numbers of dead bodies?
  

• 
  The CDC begins shipment of vaccine across the country. It has identified health care providers, elderly, and people with chronic diseases as priority populations.
  
• 
  Two doses of the vaccine will be required.
  
• 
  [Local area] receives an initial shipment of [insert a number between 5,000 and 200,000] doses to vaccinate high priority groups.
  
• 
  More vaccine is expected in the coming weeks
  

Facilitator probes:

If the public health agency is chosen:

• 
  How will public health work with its partner agencies to manage and distribute the vaccine?
  

• 
  Why is public health not the agency responsible?
  
• 
  How is the vaccine received and then distributed?
  

Probes for all partners:

• 
  How do you decide who gets the vaccine?
  
  • 
    People who have not been ill?
    
  • 
    Healthcare workers only?
    
  • 
    Families of healthcare workers?
    
  • 
    EMS?
    
  • 
    Law enforcement?
    
  • 
    Others involved in critical infrastructure?
    
• 
  How will the HHS Pandemic Influenza Plan influence your decision-making about who receives vaccines?
  

Probes for all partners:

• 
  How would vaccine inventories be monitored? How would such events as adverse medication side effects be monitored?
  
• 
  How would individuals who received the first dose be followed up for their second dose?
  
• 
  How does the vaccine get administered?
  
  • 
    Who is going to give it?
    
  • 
    Where will it be given?
    
  • 
    What recordkeeping plans will be put into place?
    
• 
  What plans would be put in place to recall people who need a second dose?
  
• 
  How do you protect the supply of vaccine?
  
• 
  How would HHS guidance get implemented? For example, what procedures would be used to verify vaccine-eligibility forms?
  

• 
  Articulated a clear, unified plan for stepped-up surveillance efforts across state lines. (Yes, within their respective states…however, across state lines this was more difficult.)
  
• 
  Understood their respective role in stepped-up surveillance efforts. (yes)
  
• 
  Articulated how their surveillance efforts dovetailed with other partner agencies. (yes)
  
• 
  Demonstrated the ability to effectively collect, share, and evaluate surveillance information in a timely manner. (Yes, the ability to do this effectively across state lines should be further explored.)
  

Epidemiology

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  Demonstrated the ability to frame relevant follow-up questions based on surveillance findings. (Yes)
  
• 
  Launched a unified epidemiologic investigation of an intensity and aggressiveness commensurate with the public health threat at each stage. (Yes)
  
• 
  Demonstrated ability to apply epidemiologic methods in crafting successive queries as hypotheses were developed, rejected, or came into greater focus. (Yes)
  

Command, Control & Communication

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  Set up a command structure that was commensurate with the threat during each stage of the exercise. (No. The agencies saw a need for a Joint Information Center, but were reluctant to put together a command structure to support it.)
  
• 
  Identified an agreed-on leader. (No)
  
• 
  Demonstrated the ability to effectively communicate with one another. (Yes, especially at the local level.)
  
• 
  Presented a unified response plan that was coordinated seamlessly across partner agencies. (Without a command structure in place… this would be difficult.)
  

Risk Communications

• 
  Worked together to carefully develop and disseminate risk communications messages. (Yes)
  
• 
  Identified a cross-agency public information leader and spoke to the media with “one voice.” (Did not identify a leader, but did attempt to speak with one voice)
  
• 
  Articulated a plan to proactively communicate with the media. (Yes, but again, this would be difficult without a command structure)
  
• 
  Developed clear and consistent messages across agencies based on facts. (Yes)
  
• 
  Demonstrated ability to effectively communicate with vulnerable communities. (Yes)
  

Surge Capacity

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  Were able to identify the availability of resources for emergency transport, emergency department care, beds, ventilators, and staff. (It was noted that this could be done with in the states, but difficult to do across borders)
  
• 
  Developed plans to share resources. (It was noted that direction from CDC would be helpful on this issue)
  
• 
  Had clear relationships with one another, including memorandums of understanding and pre-established plans for dealing with limited staff and resources. (Clear relationships were established, again plans -exist in each state, but plans that deal with issues across state lines do not.)
  

Disease Prevention and Control

• 
  Considered strategies to balance competing needs for more information versus the need for rapid action to control the disease from spreading. (Yes)
  
• 
  Possessed knowledge of, or were readily able to access, indications and contraindications for vaccination or prophylaxis. (Yes)
  
• 
  Applied available guidelines and developed a rational process to determine who should receive vaccination/prophylaxis. (Yes, this was discussed)