Foodborne Terrorism Tabletop Exercise

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Foodborne Terrorism Tabletop Exercise

• October 21, 2005

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Schedule

• 800 830 Mingling over Breakfast
• 830 900 Introduction
• 900 1115 Exercise, Phase 1
• 1115 1230 Lunch
• 1230 115 Guest Presentation
• 115 215 Exercise, Phase 2
• 215 300 Media Segment
• 300 400 Debriefing
• Breaks will occur both in the morning and
  afternoon
• at a time to be decided by the moderator.

3
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

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Special Thank You to the Planning Committee

• Tim Jones
• Ryan Mason
• Karen Patton Brady
• John Sanford

• Jerry Rowland
• Jane Richter
• Erik Svendsen
• John Dunn

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Schedule

• 800 830 Mingling over Breakfast
• 830 900 Introduction
• 900 1115 Exercise, Phase 1
• 1115 1230 Lunch
• 1230 115 Guest Presentation
• 115 215 Exercise, Phase 2
• 215 300 Media Segment
• 300 400 Debriefing
• Breaks will occur both in the morning and
  afternoon
• at a time to be decided by the moderator.

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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.

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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.

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Tabletop Exercise?

• Informal group discussion stimulated by a
  scripted disaster scenario
• Low 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

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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

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Objectives of the Exercise

• Identify gaps in local preparedness plans,
  policies and/or procedures
• Build relationships with participants from other
  key agencies
• Identify additional training needs in your
  organization/agency

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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.

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Various Roles

• Moderator Dr. Allen Craig
• Participants You
• Facilitators Planning Committee Members
• Evaluator Dr. Erik Svendsen

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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

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Instructions to Remember

• Respond as a group as the information emerges
• Maintain your agencys role throughout the
  exercise
• Not all will participate equally
• Lack of active participants does not mean lack of
  learning

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Components of Exercise

• Phase 1
• The Setting
• The Scenario Unfolds
• Various Agency Roles/Responses

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Components of Exercise

• Phase 2
• The Contamination Event
• Guest Presentation
• Media Segment
• Debriefing

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THE SETTING

• (Metropolitan Davidson County)

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The Setting

• Nashville / Davidson County, Tennessee
• 596,000 residents
• 946,000 people who commute to Nashville from
  neighboring counties

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The Setting

• Approximately 30 medical centers, including 10
  hospitals and specialty centers located
  throughout the county
• Numerous nursing homes and day care centers

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The Setting

• Public water supply
• Public Health Department of Nashville/Davidson
  Co. is a local health department with
  approximately 500 employees/ State Health Dept.

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The Setting

• Tourism and agriculture are major industries

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Day 1 Friday Afternoon

• Isnt it always?

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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.

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

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Same Day

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

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VARIOUS AGENCY ROLES/RESPONSES
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Question ?

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

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Question ?

• What would be their response?

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THE SCENARIO UNFOLDS
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Day 4Monday 1100 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.

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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.

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VARIOUS AGENCY ROLES/RESPONSES
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Question ?

• Which agencies need to concern themselves with
  this information?

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Question ?

• What would be their response?

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THE SCENARIO UNFOLDS
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Day 6Wednesday 1000 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.

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VARIOUS AGENCY ROLES/RESPONSES
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Question ?

• Which agencies should be involved?

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Question ?

• What needs to be done (and by whom) ?

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Communication

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

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THE SCENARIO UNFOLDS
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• Metro Health Dept. started interviews at 3
  schools.
• Approximately 20 of students had some
  gastrointestinal symptoms.

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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.

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• 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).

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

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• Approximately 40 of hospitalized children return
  to the hospital with similar symptoms after being
  discharged.
• None of these children have returned to school.

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• 48 Students have been seen in area ERs.
• 2 of people who reported symptoms are teachers.

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VARIOUS AGENCY ROLES/RESPONSES

• Refer to Handout 1 Event Recap.

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Question ?

• Who is in charge of the situation?

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Question ?

• What would your agencys role be now?

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Question ?

• With whom would your agency be communicating?

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THE SCENARIO UNFOLDS
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Day 6Wednesday 230 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.

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Day 7Thursday, 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.

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VARIOUS AGENCY ROLES/RESPONSES

• Handout 2

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Question ?

• Would your agency be impacted, if so, how?

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Question ?

• What are your initial actions?

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Question ?

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

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Question ?

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

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Question ?

• Who is in charge of the situation? Why?

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Question ?

• What is your agencys involvement at this point?

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THE SCENARIO UNFOLDS
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Day 8Friday 900 AM

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

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VARIOUS AGENCY ROLES/RESPONSES
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Question

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

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Question

• Who would be responding?

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Question

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

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THE SCENARIO UNFOLDS
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Day 11MondayEpi. 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.

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Same Day

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

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Epidemiological Investigation Reveals

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

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VARIOUS AGENCY ROLES/RESPONSES

• Handout 3

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Question ?

• What are your agencys urgent priorities now?

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Question ?

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

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Question ?

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

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Question ?

• Which aspects of the investigation/situation have
  changed?

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Question ?

• Who is in charge of the situation? Why?

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Question ?

• What are your resources?

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THE CONTAMINATION EVENT
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Day 18 Monday 400 pm

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

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Effects on your agency?

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

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Radiation Exposure
Crash Course
CAUTION
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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

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Sources Around the World
Sources used in mobile cesium irradiators in the
former Soviet Union
Recovered transport container
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(No Transcript)
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Goiânia Morbidity

• 249 exposed 54 hospitalized
• Eight with radiation sickness
• Four people died
• 112,000 people monitored (gt10 of total
  population)

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What Is Radiation?
Radio/TV
Sun
Nuclear
Heat
Light
Microwave
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Radiation is NOT contagious!
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Electromagnetic Spectrum
Energy
Electrical Power
Microwave
Radio/TV
Light
X-ray
Gamma
UV
NON-IONIZING RADIATION
IONIZING RADIATION
Frequency
90
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

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Types of Ionizing Radiation
Alpha Particles Stopped by a sheet of paper
Radiation Source
Beta Particles Stopped by a layer of clothing or
less than an inch of a substance (e.g. plastic)
Gamma Rays Stopped by inches to feet of
concrete or less than an inch of lead
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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

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Examples of Radioactive Materials
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
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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

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Reducing Radiation Exposure

• Time
• Distance
• Shielding

Decrease time spent near the radioactive source
Increase distance between you and the source
Increase the physical shielding between you and
the source
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Protective Action Guides

• Sheltering
• Evacuation
• Relocation
• Decontamination
• Worker PPE

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Common Shelters
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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

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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

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Radiation Exposure Types
Internal Contamination
External Contamination

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Basic Mechanism

• DNA is the primary target for biological effects

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Health Effects of Radiation Exposure

• Lethal at high doses
• Mutagenic
• Carcinogenic
• Other biological effects, especially at high doses

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Radionuclide Uptake
Inhalation
Surface
Intake
Ingestion
Lung Clearance
Lung
Skin 1. Intact 2. Wounds
GI Tract
Lymph Nodes
Uptake
Blood
(Recycle)
Kidney
Deposition Sites
1. Whole Body 2. Bone 3. Liver 4. Thyroid
Excretion
Feces
Urine
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Patient Management - Triage

• Triage based on
• Injuries
• Signs and symptoms - nausea, vomiting, fatigue,
  diarrhea
• History - Where were you when the bomb
  exploded?
• Contamination survey

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Treatment for Unknown Radionuclide

• Unless treatment is instituted quickly, its
  effectiveness will be limited.
• Use of emetics, lavage, charcoal, and/or
  laxatives are common.

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Treatment of Internal Contamination

• Radionuclide-specific
• Most effective when administered early
• May need to act on preliminary information

Radionuclide Treatment Route Cesium-137 Prussia
n blue Oral Iodine-125/131 Potassium
iodide Oral Strontium-90 Aluminum
phosphate Oral Americium-241/ Ca- and Zn-DTPA IV
infusion, Plutonium-239/ nebulizer Cobalt-60
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Surface ContaminationInjury

• First irrigate wounds, then follow the same
  clothing removal and washing routine.
• After decontamination, continue to treat wounds
  in the usual manner.

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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

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All Emergencies Are Local
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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

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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

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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

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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)

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(No Transcript)
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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

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Long-term Response Issues

• Application of EPA and FDA Protective Action
  Guides
• Food and water
• Non-food use of agricultural products
• Recovery operations
• Develop plans for decontamination, re-entry, and
  recovery of affected areas

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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

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Day 18 Monday 400 pm

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

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VARIOUS AGENCY ROLES/RESPONSES

• Handout 4

120
Question ?

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

121
Question ?

• Who in your agency would be involved in the
  response?

122
Question ?

• Who is your agencys primary point of contact?

123
Question ?

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

124
Question ?

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

125
Question ?

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

126
Question ?

• Who is in charge of the situation? Why?

127
MEDIA SEGMENT
128
THE SCENARIO UNFOLDS
129

• 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.

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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.

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THE DEBRIEFING
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Debriefing

• Discuss the events of the exercise
• Identify gaps in plans, policies, and procedures
• Identify useful information (effective responses)
• Plan next steps
• Complete evaluation forms