TOPOFF 3David Gruber

Assistant Commissioner - NJDHSSDivision of Emergency

Preparedness and Response

Joseph A. BaroneProfessor and Chair - EMSOPChair - Executive Council –

MEDPREP

Acknowledgements

Dave Gruber, Jim Blumenstock, Commissioner Jacobs

NJ OEM and State Police Middlesex County Public Health Dept.

Connecticut Dept. of Public Health

Scotland Yard

TOPOFF 3 “Live” Video

VNN

New Jersey’s Overarching Objectives

1. Administer effective and efficient prophylaxis distribution.

2. Identify necessary staffing patterns for the “comprehensive” health care system.

3. Exercise the disaster-declaration process.

4. Examine the processes associated with quarantine and/or isolation orders.

5. Explore the existing hospital capacities and related administrative systems.

6. Examine continuity of government and business operations in public and private sectors.

Overarching Objectives (cont)

7. Test the epidemiological processes and procedures to include the coordination of health care activities with law enforcement.

8. Examine the in-State resources and Federal support for mortuary care.

9. Evaluate the effectiveness of the EMAC. 10. Assess existing mental health strategies

for emergency workers and the public. 11. Explore the coordination of intelligence

and investigative authorities. 12. Test the abilities of State and local

governments and the private sector to conduct Risk Assessment, and manage a public information program.

Scenario

Planned covert release of Yersinia pestis in NYC 04 April

Operation is compromised prompting early release in NJ (2 April)

Linked to attack in New London

Linked to UK and Canada (direct/indirect)

Driving Routes

Total Cases of Pneumonic Plague

5000+

2501-5000

1501-2500

501-1500

101-500

0-100

Day One: Monday 4 APR 05 CountyCumulative

Cases

Union 453

Middlesex 384

Essex 64

Hudson 36

Monmouth 31

Somerset 18

Passaic 17

Bergen 16

Morris 9

Mercer 7

Burlington 6

Ocean 5

Sussex 6

Warren 5

Hunterdon 3

Camden 2

Gloucester 2

Salem 1

Atlantic 1

Cumberland 1

Cape May 1

TOTAL 1068

Total Cases of Pneumonic Plague

5000+

2501-5000

1501-2500

501-1500

101-500

0-100

CountyCumulative

Cases

Union 6436

Middlesex 6155

Essex 3212

Hudson 3190

Monmouth 2773

Somerset 1748

Passaic 2109

Bergen 2044

Morris 1587

Mercer 1542

Burlington 1038

Ocean 978

Sussex 836

Warren 782

Hunterdon 760

Camden 742

Gloucester 672

Salem 558

Atlantic 523

Cumberland 133

Cape May 118

TOTAL 37936

Day Five: Friday 8 APR 05

Local public health and health care partners

NJDHSS Communicable Disease Service

CDC animal/vectorteam*

CDC epidemiology team (on-site)

Reports of:•Suspect human cases•Animal die-offs

NJ Department of Agriculture

* Notional play

Yersinia pestisYersinia pestis confirmed* confirmed*

~30,000 human plague cases (~30% mortality)*~30,000 human plague cases (~30% mortality)*

~500 animal cases in rabbits and cats ~500 animal cases in rabbits and cats (~40% mortality)*(~40% mortality)*

State Medical Examiner*

•Consultation•Epidemiologic assistance

T3 Main Events: Summary

CDC NCID*

NJ PHEL

•Lab testing

•Death counts

Overview Hospitalized 30,000+ Fatalities 8000+ All state acute care hospitals participate (FQHCs)

SNS received (Push package + VMI) 22 PODs opened throughout state (actual), 400+ notional (LINCS agencies)

SEOC,HCC,CEOC open Joint FBI Public Health Epi investigation FBI takedown of bio-lab NJSP takedown of safe house JOC,JFO,JIC stand up

Now the fun stuff

The Full Scale Exercise

D-Day

The FSE

The 1st Response

•Computer programmable training aids present physiological signs and symptoms associated with chemical, biological, nuclear, radiological, and explosive events and respond realistically to the medical procedures of responders

•Supports overall trauma and mass casualty incident medical training

•Will provide training to hospital, EMS, and non-hospital based healthcare professionals

•Part of the State’s mass casualty incident training program (trainers will use all mannequins (10) at a single site to enhance the realism of a simulated mass casualty incident)

Health Simulation Mannequins

Operation Exodus

The Evacuation of the “Healthy Sick” During

TOPOFF 3

Operation Exodus

Transfer approximately 100 non-infected “healthy sick” patients from (8) eight hospitals/facilities in northern and central New Jersey

Evacuate these patients to other areas of the country via military aircraft in concert with NDMS

Operation Exodus

12 “Strike Teams” were dispatched to (8) Eight Sending Health Care Facilities

(7) Seven Acute Care Hospitals

(1) One Long Term Care facility

Operation Exodus

67 Ambulance Teams Participated: 26 Licensed 41 Volunteer

Staging : Meadowlands PNC Arts Center

Operation ExodusLoaded Stretcher Patients

Strategic National Stockpile Operations

• Be careful what you don’t ask for (10M doses)

• Just cause you got it, doesn’t mean you got it (Fed release)

• Even when you finally get it, doesn’t mean you can use it (Cipro for plague)

VMI focus

How much is too much

County/local ability to receive

Command, Control, Communications

Lab

Op

s

IT

Hu

man

Services

Hospitals/FQ

HC

/

LTC

Public Health

Logistic (SNS/SSS)

HA

N

Fed

eral

Cel

lE

MS

PIO

Ad

min

Lab Building

OIT

SRSS

Off si

te o

ps

CDRS

Epi Investig

ation

JICJOC

FB

I

OC

T

DH

SD

EP

Phon

eG

ov

offic

e

EMS/General

OEM EOC

AG

HH

S

CD

C

Hospita

ls

EMS DispatchEMS TF

Press

BENS

Public

PODSLINCSNJH

A

Me

dic

al

Co

mm

and

HCO&A

DHSSDHSS

Govt. AgenciesGovt. Agencies

Other

Other

Agenci

es/O

rgs

Agenci

es/O

rgs

NJDHSS•Health Command Center (HCC)•Receipt/Stage/Storage Site (RSS)•Emergency Communication Center (ECC)

State Police Office of Emergency Management (OEM)•Emergency Operations Center (EOC)

Joint Operations Center (JOC)/ Joint Field Office (JFO)

Federal •DHS, FBI, DHHS, CDC

State•Attorney General’s Office, NJDHSS, OEM

Local health departments

County OEMsAcute care hospitals

T3 command and control structure– federal, state and local partnersL

oca

lS

tate

Fed

eral

/sta

te

Command, Control, Management

Observations Federal officials in NJ–> roles unclear yet. . .

NJ made policy decisions without adequate intelligence input and federal perspective

Command, Control, Management

Lessons learned Need to identify all potential federal resources and attempt to optimize interface with federal agencies in advance

Need to ensure that state is involved in decision process regarding federal assets

Need to ensure that federal agencies acknowledge any state request with written documentation

Tuesday Evening: The Magic Begins

• Conference call NJ, JFO, White House/HHS/DHS

• Feds go postal

• NJ says “yo”

NOTIONALITY, the Miracle Drug

• Medications (10M doses before disease identified)

• PODS (post offices)

• People (15K NJ workers)

• Medical professionals (25K surrounding states)

• Medical Facilities (10K bed hospital)

Medication Delivery

Observations Ciprofloxacin and gentamicin lack FDA approval for treatment and prophylaxis of plague IND protocol for use; challenges in getting written Emergency Use Authorization

Adverse events routine reporting mechanisms through FDA

Medication DeliveryObservations Federally-operated PODs unclear whether operating under considerations (e.g., safety, facilitated crowd movement) as outlined in NJDHSS POD manual

No limits regarding antibiotics received from SNS but. . .

“Competition” with other states for limited resources

Medication Delivery

Lessons learned Need to consider alternate POD model(s) to accommodate mass non-targeted prophylaxis distribution (e.g., antibiotics to entire state during T3) Arrangements with Departments of Corrections and Human Services, regarding confined living facilities

Partnerships with industry, “taking care of their own”; first responders

22 regional PODs, local health department assets

267 PODs, state assets* 189 PODs, federal assets* (e.g., U.S. Postal Service resources)

* Notional play

> 400 PODs statewide*> 400 PODs statewide*

> 10 million doses of antibiotic > 10 million doses of antibiotic prophylaxis distributed* prophylaxis distributed*

T3 Main Events: Summary

Medical Surge CapacityObservations NJ able to shift resources inter- and intra-state

Request for assets without numbers to support decisions

Lessons learned If alternate site facilities that cannot provide maximal levels of medical care are used, need to factor in ethical considerations when triaging patients to these facilities

Medical Surge Capacity

Lessons learned Need to consider limited resources and supplies, in face of “competition” with other states and within own state Consider individual facility stockpiling of supplies (learn from “shortages”)

Decreased staff numbers and those with special skills/training “just in time” training

“Snow-day” model

Communications: Public Information

Observations Overall, consistent messages facilitated through: Multi-agency coordination to adapt and respond to evolving event

Use of prepackaged materials (“shelf kits”) and regular communication with local agencies and hospitals

Communications: Public Information

Observations Overall, consistent messages facilitated through: Multi-agency coordination to adapt and respond to evolving event

Use of prepackaged materials (“shelf kits”) and regular communication with local agencies and hospitals

Communications

Lessons learned Continue to ensure “one message” representing all agencies involved Medication recommendations Infection control and personal protective equipment recommendations (e.g., anticipate N95 v. surgical mask discussion also in pandemic influenza event)

Educational materials Make sure that all assets are in the loop

Blood Center Operations

Observations American Association of Blood Banks Inter-organizational Task Force activated to address donor deferral and quarantine

National Blood Exchange emergency blood supply to NJ not all NJ blood centers apprised of process for receiving deliveries*

* Notional play

What does it mean to go “RED”

Food Sector Activities

Observations Inter- and intra-state travel restrictions initially entertained during early phases of outbreak devastating effect on food distribution*

Decisions based on inadequate intelligence, need to do something

* Notional play

Food Sector Activities

Lessons learned NJ Food Council’s Food Sector Advisory Committee: Consider master plan to share sector resources, locations, inventory

Develop company-specific plans for retail store or distribution center regarding restoring product supply and staffing

Barone’s Observations

We are better prepared Systems can get quickly overwhelmed

The little things will screw you up

There are lots of moving parts Need to have processes in place and DRILL, DRILL, DRILL

Good Advice

Do no harm