foodborne terrorism tabletop exercise october 21, 2005

Foodborne Terrorism Foodborne Terrorism Tabletop ExerciseTabletop Exercise

October 21, 2005

Schedule

8:00 – 8:30 Mingling over Breakfast 8:30 – 9:00 Introduction 9:00 – 11:15 Exercise, Phase 1 11:15 – 12:30 Lunch 12:30 – 1:15 Guest

Presentation 1:15 – 2:15 Exercise, Phase 2 2:15 – 3:00 Media Segment 3:00 – 4:00 Debriefing

Breaks will occur both in the morning and afternoon

at a time to be decided by the moderator.

Acknowledgements

Sponsored by the TN Food Safety Taskforce Funding from The University of South Carolina

Center for Public Health Preparedness Developed by TN Department of Health in

conjunction with TN Dept. of Agriculture, Metro Public Health Department of Nashville/Davidson Co., and Center for Public Health Preparedness, University of South Carolina

Special Thank You to the Planning Committee

Tim JonesRyan MasonKaren Patton

Brady John Sanford

Jerry Rowland Jane RichterErik Svendsen John Dunn

Schedule

8:00 – 8:30 Mingling over Breakfast

8:30 – 9:00 Introduction 9:00 – 11:15 Exercise, Phase 1 11:15 – 12:30 Lunch 12:30 – 1:15 Guest Presentation 1:15 – 2:15 Exercise, Phase 2 2:15 – 3:00 Media Segment 3:00 – 4:00 Debriefing

Breaks will occur both in the morning and afternoon at a time to be decided by the moderator.

Purpose

This tabletop exercise will enable participants to demonstrate and evaluate the response capabilities, communication, resources, data, coordination, and organizational elements involved in a food security emergency response.

Purpose

Participants will have an opportunity to assess their own preparedness for responding to such a scenario and identify individual needs for information and/or training.

Tabletop Exercise? Informal group discussion stimulated

by a scripted disaster scenarioLow stress, designed to promote free

and open exchange of ideas Identify issues (e.g., data,

coordination, communication, resources, and policy)

Familiarize players with roles, functions, plans, and procedures

Objectives of the Exercise Identify the policy issues that would

arise during a food-related terrorism event

Identify and understand measures that can be performed at the local level

Recognize the roles of various public officials

Illustrate the need for intense teamwork and communication

Objectives of the Exercise Identify gaps in local preparedness

plans, policies and/or proceduresBuild relationships with participants

from other key agencies Identify additional training needs in

your organization/agency

House Rules This is an exercise only. Please preface and end all

phone calls pertaining to this exercise which extend outside of this facility with the statement “this is an exercise”.

What happens in this room stays in this room with the exception of the lessons we learn and the relationships we develop.

Please be sensitive to the noise level. Above all, courtesy and professionalism prevail. Name tags are required at all times. There will be no actual news media involved in this

exercise.

Various Roles

Moderator – Dr. Allen CraigParticipants – You Facilitators – Planning Committee

MembersEvaluator – Dr. Erik Svendsen

Participants’ Roles

Play your own role in your agency (if possible)

Identify gaps and strengths of response plans

Take note of perceived deficiencies to be discussed during The Debriefing

Instructions to Remember

Respond as a group as the information emerges

Maintain your agency’s role throughout the exercise

Not all will participate equally Lack of active participants does not mean

lack of learning

Components of Exercise

Phase 1The SettingThe Scenario UnfoldsVarious Agency Roles/Responses

Components of Exercise

Phase 2The Contamination EventGuest PresentationMedia SegmentDebriefing

THE SETTINGTHE SETTING

(Metropolitan Davidson County)

The Setting

Nashville / Davidson County, Tennessee

596,000 residents

946,000 people who commute to Nashville from neighboring counties

The Setting

Approximately 30 medical centers, including 10 hospitals and specialty centers located throughout the county

Numerous nursing homes and day care centers

The Setting

Public water supplyPublic Health Department of

Nashville/Davidson Co. is a local health department with approximately 500 employees/ State Health Dept.

The Setting

Tourism and agriculture are major industries

Day 1 – Day 1 – Friday AfternoonFriday Afternoon

Isn’t it always?

Phone Call

Mary, school nurse from Dan Mills Elementary School (Metro-Davidson Co.) calls the Metro Health Department concerned that 4 children, (ages 6-9), have reported to her clinic, ill, with vomiting and diarrhea, 1 of which is bloody diarrhea.

Parents have been called, and are on their way to pick up their children.

Same Day

Health Department advises obtaining stool samples, which were collected and submitted to Vanderbilt ER (4 Total).

Results are pending.

VARIOUS AGENCY VARIOUS AGENCY ROLES/RESPONSESROLES/RESPONSES

Question ?

Which agencies do you think need to concern themselves with this information?

Question ?

What would be their response?

THE SCENARIO THE SCENARIO UNFOLDSUNFOLDS

Day 4—Monday 11:00 am

School nurses from Bellevue Middle and Crieve Hall Elementary report to Metro Health Dept. that 7 and 4 children, respectively, are exhibiting symptoms of vomiting and diarrhea with 3 children also experiencing bloody diarrhea.

Same Day

The ages of the children ranged from 6-13. Several of the sick children apparently

have not been in contact with any of the other children who exhibited similar symptoms.

No Link has been established between the groups of ill children.

VARIOUS AGENCY VARIOUS AGENCY ROLES/RESPONSESROLES/RESPONSES

Question ?

Which agencies need to concern themselves with this information?

Question ?

What would be their response?

THE SCENARIO THE SCENARIO UNFOLDSUNFOLDS

Day 6—Wednesday 10:00 am

Private practice physicians are reporting an unusual number of sick children (symptoms of nausea and vomiting) to the Metro Health Department.

Concerned parents, hearing rumors of food poisoning are also calling schools and the Department of Education in an attempt to get more information.

VARIOUS AGENCY VARIOUS AGENCY ROLES/RESPONSESROLES/RESPONSES

Question ?

Which agencies should be involved?

Question ?

What needs to be done (and by whom) ?

Communication

Who needs to be communicating with whom (and why) ?

THE SCENARIO THE SCENARIO UNFOLDSUNFOLDS

Metro Health Dept. started interviews at 3 schools.

Approximately 20% of students had some gastrointestinal symptoms.

Ongoing Epidemiological Investigation Reveals…

No adult family members are presenting these symptoms.

Most of the sick children ate at school cafeterias, but some brought lunch and only bought milk or juice at the cafeteria.

Metro environmental health specialists (health inspectors) report cafeteria inspection scores are 94 and 98 for Bellevue Middle and Crieve Hall Elementary Schools (no critical or serious violations were observed).

One inspector even remarked that Bellevue Middle Cafeteria was the cleanest one he had ever seen.

Approximately 40% of hospitalized children return to the hospital with similar symptoms after being discharged.

None of these children have returned to school.

48 Students have been seen in area ER’s.

2% of people who reported symptoms are teachers.

VARIOUS AGENCY VARIOUS AGENCY ROLES/RESPONSESROLES/RESPONSES

Refer to Handout # 1: Event Recap.

Question ?

Who is in charge of the situation?

Question ?

What would your agency’s role be now?

Question ?

With whom would your agency be communicating?

THE SCENARIO THE SCENARIO UNFOLDSUNFOLDS

Day 6—Wednesday 2:30 PM(Same Day)

All stool cultures from ill people are negative.

TN State Dept. of Education reports that absenteeism is up 18% in eleven counties in Middle TN.

Day 7—Thursday, throughout day

Epi-X (surveillance tracking software) reveals to state epidemiologists that Huntsville, AL; Rome, GA, Hopkinsville and Louisville, KY and their surrounding areas are all reporting similar activity.

VARIOUS AGENCY VARIOUS AGENCY ROLES/RESPONSESROLES/RESPONSES

Handout # 2

Question ?

Would your agency be impacted, if so, how?

Question ?

What are your initial actions?

Question ?

Within your own agency, with whom would you communicate first? Why? Others and why?

Question ?

Due to the negative stool culture results and interstate involvement, which aspects of the investigation would change?

Question ?

Who is in charge of the situation? Why?

Question ?

What is your agency’s involvement at this point?

THE SCENARIO THE SCENARIO UNFOLDSUNFOLDS

Day 8—Friday 9:00 AM

Media picks up story about possible strain of stomach flu raging through the community and nearby areas of AL, KY, and GA.

VARIOUS AGENCY VARIOUS AGENCY ROLES/RESPONSESROLES/RESPONSES

Question

Would your agency be talking to the media about this issue?

Question

Who would be responding?

Question

Outside your agency, with whom would you communicate first? Why? Others and why?

THE SCENARIO THE SCENARIO UNFOLDSUNFOLDS

Day 11—MondayEpi. Investigation Reveals…

Another cluster of cases with similar symptoms was uncovered through an investigation of local hospital records. Several employees of Sunrise Dairy have been out of work sick for nearly 2 weeks, many have been hospitalized, and some keep returning to the hospital.

Same Day

Vanderbilt Children’s Hospital notifies the Metro Nashville Health Department that two of the sick children from Crieve Hall Elementary School have died.

Epidemiological Investigation Reveals…

Metro Health Dept. implicates milk as being associated with the ‘unknown’ sickness (odds ratio of 8.3).

VARIOUS AGENCY VARIOUS AGENCY ROLES/RESPONSESROLES/RESPONSES

Handout # 3

Question ?

What are your agency’s urgent priorities now?

Question ?

Within your agency, with whom would you communicate first? Why? Others and why?

Question ?

With whom would you be communicating outside your agency? Why?

Question ?

Which aspects of the investigation/situation have changed?

Question ?

Who is in charge of the situation? Why?

Question ?

What are your resources?

THE THE CONTAMINATION CONTAMINATION

EVENTEVENT

Day 18 –Monday 4:00 pm

Letter received at WSMV, a local news station, from a terrorist claiming responsibility for contamination of milk with a radioactive material.

Effects on your agency?

Media onslaught !Personal concerns and fears !Community reaction ! Magnitude of public inquiry !Financial implications !

Radiation Exposure

CAUTION

Crash Course

Radioactive Sources

• 157,000 licensed users in U.S.

• 2,000,000 devices containing radioactive sources

• Approximately 400 sources lost or stolen in U.S. every year

Sources used in mobile cesium Sources used in mobile cesium irradiators in the former Soviet irradiators in the former Soviet

UnionUnion

Recovered Recovered transport transport containercontainer

Sources Around the Sources Around the WorldWorld

Goiânia Morbidity

• 249 exposed; 54 hospitalized

• Eight with radiation sickness

• Four people died

• 112,000 people monitored (>10% of total population)

What Is Radiation?

Nuclear

Radio/TV

Sun

Light

Heat

Microwave

Radiation is NOT contagious!

Electromagnetic SpectrumEnergyEnergy

ElectricalElectricalPowerPower

Radio/Radio/TVTV

MicrowaMicrowaveve

LightLight

NON-IONIZING NON-IONIZING RADIATIONRADIATION

X-X-rayray

GamGammama

IONIZING IONIZING RADIATIONRADIATION

FrequencyFrequency

UVUV

Ionizing Radiation

• Ionizing radiation is radiation capable of imparting its energy to the body and causing chemical changes

• Ionizing radiation is emitted by

- Radioactive material

- Some devices such as x-ray machines

Types of Ionizing Radiation

Alpha ParticlesStopped by a sheet of paper

Beta ParticlesStopped by a layer of clothingor less than an inch of a substance (e.g. plastic)

Gamma RaysStopped by inches to feet of concreteor less than an inch of lead

RadiationSource

Radiation Doses and Limits

Flight from Los Angeles to London 5 mrem

Annual public dose limit 100 mrem

Annual natural background 300 mrem

Fetal dose limit 500 mrem

Barium enema 870 mrem

Annual radiation worker dose limit 5,000 mrem

Heart catheterization (skin dose) 45,000 mrem

Life saving actions guidance (NCRP-116) 50,000 mrem

Mild acute radiation syndrome 200,000 mrem

LD50/60 for humans (bone marrow dose) 350,000 mrem

Radiation therapy (localized & fractionated) 6,000,000 mrem

Physical Radionuclide Half-Life Activity Use

Cesium-137 30 yrs 1.5x106 Ci Food Irradiator

Cobalt-60 5 yrs 15,000 Ci Cancer Therapy

Plutonium-239 24,000 yrs 600 Ci Nuclear Weapon

Iridium-192 74 days 100 Ci Industrial Radiography

Hydrogen-3 12 yrs 12 Ci Exit Signs

Strontium-90 29 yrs 0.1 Ci Eye Therapy Device

Iodine-131 8 days 0.015 Ci Nuclear Medicine Therapy

Technetium-99m 6 hrs 0.025 Ci Diagnostic Imaging

Americium-241 432 yrs 0.000005 Ci Smoke Detectors

Radon-222 4 days 1 pCi/l Environmental Level

Examples of Radioactive Materials

Causes of Radiation Exposure/Contamination

• Accidents

– Nuclear reactor

– Medical radiation therapy

– Industrial irradiator

– Lost/stolen radioactive sources

– Transportation

• Terrorist Event

– Radiological dispersal device (dirty bomb)

– Attack on or sabotage of a nuclear facility

– Low yield nuclear weapon

Time:

Distance:

Shielding:

IncreaseIncrease distance distance between you and the between you and the sourcesource

DecreaseDecrease time spent time spent near the radioactive near the radioactive sourcesource

Increase Increase the the physical shielding physical shielding between you and between you and the sourcethe source

Reducing Radiation Exposure

Protective Action Guides

• Sheltering

• Evacuation

• Relocation

• Decontamination

• Worker PPE

Common Shelters

Structure Dose Reduction Factors

Wood Frame (1st floor) 10%

Wood Frame (Basement) 40%

Masonry 40%

Large building 80%

Protective Actions

• If you are inside, shelter in place– Stay indoors– Turn off ventilation systems– Close and lock windows and doors

• If you are outside,– Cover your nose and mouth with a

cloth– Leave the area and go inside

Protective Actions

• If you think you may be contaminated,

– Remove outer layer of clothing and seal it in a plastic bag

– Shower or wash your hands and face

• Listen for further instructions

• Seek medical attention only for severe injuries

IrradiationIrradiation Internal Internal ContaminationContamination

External External ContaminationContamination

Radiation Exposure TypesRadiation Exposure TypesRadiation Exposure TypesRadiation Exposure Types

****

****

Basic Mechanism

DNA is the primary target for biological effects

Health Effects of Radiation Exposure

• Lethal at high doses

• Mutagenic

• Carcinogenic

• Other biological effects, especially at high doses

IngestionIngestion InhalationInhalation SurfaceSurface

LymphLymphNodesNodes

LungLung SkinSkin1. Intact1. Intact2. Wounds2. Wounds

BloodBlood

KidneyKidney Deposition SitesDeposition Sites

FecesFeces UrineUrine

1. Whole Body1. Whole Body2. Bone2. Bone3. Liver3. Liver

4. Thyroid4. Thyroid

Intake:Intake:

Uptake:Uptake:

Excretion:Excretion:

GIGITractTract

(Recycle)(Recycle)

Lung ClearanceLung Clearance

Radionuclide Uptake

Patient Management - Triage

Triage based on:

• Injuries

• Signs and symptoms - nausea, vomiting, fatigue, diarrhea

• History - Where were you when the bomb exploded?

• Contamination survey

Treatment for Unknown Radionuclide

• Unless treatment is instituted quickly, its effectiveness will be limited.

• Use of emetics, lavage, charcoal, and/or laxatives are common.

• Radionuclide-specific

• Most effective when administered early

• May need to act on preliminary information

Treatment of Internal Contamination

Radionuclide TreatmentRoute

Cesium-137 Prussian blue Oral

Iodine-125/131 Potassium iodide Oral

Strontium-90 Aluminum phosphate Oral

Americium-241/ Ca- and Zn-DTPA IV infusion,Plutonium-239/nebulizerCobalt-60

Surface Contamination…Injury

• First irrigate wounds, then follow the same clothing removal and washing routine.

• After decontamination, continue to treat wounds in the usual manner.

Key Points• Medical stabilization is the highest priority

• Train/drill to ensure competence and confidence

• Pre-plan to ensure adequate supplies and survey instruments are available

• Universal precautions and decontaminating patients minimizes exposure and contamination risk

• Early symptoms and their intensity are an indication of the severity of the radiation injury

• The first 24 hours are the worst; then you will likely have many additional resources

All Emergencies Are Local

Terrorist Attack

Local Public Health Response Organizations

State Public Health Response Organizations

Federal Public Health Response Organizations

Local Government Responsibilities

• Local Chief Executive Officer (i.e., mayor, city or county manager)

– Coordinates local resources

– Suspends local laws or ordinances Communicates with the public

State and Local Public Health Response

• Monitor workers’ health and safety

• Assure safe shelters and healthy food and water supplies

• Coordinate sampling and laboratory analysis of samples

State and Local Public Health Response

• Field investigations and monitoring of people

• Criteria for entry and operations at the incident site

• Disease control and prevention measures

Medical Support

• Evaluate health and medical impacts on the public and emergency personnel

• Develop medical intervention recommendations

• Treat impacted citizens

• Request Strategic National Stockpile (formerly National Pharmaceutical Stockpile)

Facility Recovery

• Remove waste from the treatment area

• Survey facility for contamination

• Decontaminate as necessary

– Normal cleaning routines (mop, strip waxed floors) typically very effective

– Periodically reassess contamination levels

– Replace furniture, floor tiles, etc. that cannot be adequately decontaminated

• Goal: Less than twice normal background… higher levels may be acceptable

Long-term Response Issues

• Surveillance and epidemiological studies

• Establish exposure registry and monitor long-term impacts

• Provide information to public and responders on long-term health effects

Day 18 –Monday 4:00 pm

Letter received at WSMV, a local news station, from a terrorist claiming responsibility for contamination of milk with a radioactive material.

VARIOUS AGENCY VARIOUS AGENCY ROLES/RESPONSESROLES/RESPONSES

Handout # 4

Question ?

How would this new information change the investigation/situation for your agency?

Question ?

Who in your agency would be involved in the response?

Question ?

Who is your agency’s primary point of contact?

Question ?

With which other agencies would you be communicating? With whom exactly?

Question ?

What are the three most urgent priorities for your agency at this point?

Question ?

What resources does your agency have for the response? Where are they located? How will you access and mobilize them?

Question ?

Who is in charge of the situation? Why?

MEDIA SEGMENTMEDIA SEGMENT

THE SCENARIO THE SCENARIO UNFOLDSUNFOLDS

Various agencies deployed to the Sunrise Dairy production facility to confirm presence and extent of residual radiation.

Geiger counters measure radiation, identifies one milk-storage silo.

Investigation Reveals….

Law enforcement personnel trace source back to 2 suspects, get confessions, and learn through interrogation that 2 other suspects have died, likely due to exposure.

Law enforcement personnel learn that 64 grams of Cesium-137 were placed in milk tanker by 4 terrorists.

THE DEBRIEFINGTHE DEBRIEFING

Debriefing

Discuss the events of the exercise Identify gaps in plans, policies, and

procedures Identify useful information (effective

responses)Plan next stepsComplete evaluation forms