Lessons Learned from the Avian Flu Outbreak and Vaccination Drill, June 2004

State: CA Type: Model Practice Year: 2005

Lessons Learned from the Avian Flu Outbreak and Vaccination Drill is a collaborative model for epidemiologic response to a large-scale communicable disease outbreak. This model is targeted to a large audience including: local, state and university health department epidemiologists and disease investigators; infectious disease practitioners; medical, mental, and emergency preparedness personnel from local hospitals, clinics, and EMS agencies; and the public at large. The program's goal is to train and coordinate multi-agency medical and emergency preparedness personnel to carry out the following objectives: Identify & conduct epidemiologic investigations of patients "ill" or "exposed" to life-threatening communicable disease.  Demonstrate appropriate use of infectious disease precautions while interviewing, transporting and treating patients.  Control spread of disease through treatment, education, isolation and quarantine. Rapidly provide mass prophylaxis to large numbers of persons.
Avian Influenza has been recently cited as one of the major risks for an emerging pandemic flu epidemic by both CDC and WHO. All health jurisdictions in the nation are mandated to prepare plans for rapidly detecting, responding and controlling communicable diseases. The Avian Flu Outbreak Investigation Drill set up a collaborative model for epidemiologic response to a large-scale communicable disease outbreak. The health department conducted a coordinated response by local, state and university epidemiologists and developed case & contact templates, disease scenarios and plans for treatment, prophylaxis and isolation of patients ill or exposed to a serious life-threatening communicable disease. Many health departments have exercised mass vaccination procedures or have done tabletop drills to test multi-agency communications in disease outbreaks. The Yolo County Avian Flu Disease Investigation Drill was the first disease outbreak exercise in the nation to: 1) address a communicable form of Avian Flu, cited by CDC and WHO as one of the greatest potential communicable disease risk to the world population , 2) coordinate a full-scale FIELD exercise to train health care personnel in epidemiologic investigation and implementation of control measures for responding to a large number of "patients" ill or exposed to Avian Flu and 3) coordinate this effort with epidemiologists involving twelve county jurisdictions, state public health agencies and local universities. The department has also developed templates for replicating the exercise with case & contact schematics, interviewing forms, isolation and quarantine orders and posted all on our web site (, search: Avian Flu Drill) for other agencies to use and modify.
Agency Community RolesThe local health department took the lead role as the agency responsible for detecting, responding and controlling the spread of a communicable disease. The Local Health Department established several collaborative workgroups involving representatives from multiple public health departments, local universities and health care and medical emergency response agencies during the months preceding the exercise. Epidemiologists, infectious disease control personnel and medical students from local health departments, California State Dept of Health Services and the University formed a workgroup that met weekly to develop the epidemiologic investigation scenario for cases and contacts, fact sheets about Avian Flu based on real and projected communicable properties, a model vaccine and anticipated vaccine contraindications and measures for isolation and quarantine. Local health department and university emergency preparedness coordinators along with staff from the Red Cross, Mental Health and Office of Emergency Services prepared for a mass vaccination response to protect the unexposed population. A third workgroup of personnel from the local hospitals, community clinics and EMS agencies planned for transport, treatment and isolation of “affected” patients.  Costs and ExpendituresThe greatest costs are staff time in planning and coordination. Some items used in the exercise had been previously purchased and kept in stockpile in the event of a real emergency. Additional costs of purchasing reusable supplies (i.e., safety vests, office supplies) and time involved in initial development of documents and research into previous practice and models will be lessened in repeat exercises. The program only accounted for staff time and costs at the local health department. For those involved in infectious disease control and emergency public health planning, the staff time devoted to this exercise was included as part of their normal job expectations and NOT included in the cost estimates. Costs: Staff costs for nearly 60 additional local health department staff for pre-event training and participation during the day of the exercise was approximately $22,000. Additional costs of $10,000 included equipment rental, food, incentives, non-reusable gloves and masks, copying and paper. In-kind: No costs were included for staff time from other agencies. Several local physicians, nurses, DMAT, college students and community residents volunteered 2-8 hours time for the exercise. The neighboring counties provided “in-kind” videos and photography. Some local stores donated water or food. Funding: Local health jurisdictions throughout the country received CDC bioterrorism and public health emergency preparedness grant funds which can be used towards these exercises. Some of our partner agencies were also able to support staff time for those also involved in infectious disease control or emergency planning.  ImplementationThe purpose of the exercise was to train health and emergency medical personnel in planning for and responding to large scale disease outbreaks. The most proven method to assure an effective response to a real event is to practice a well-coordinated multi-agency field exercise. The Avian Flu Disease Investigation and Mass Vaccination Drill was a multi-faceted exercise. Key agencies were identified which would be responsible or would assist in this response. A core group of three health department emergency preparedness planners met regularly to coordinate the whole event. These three coordinators had each participated in similar planning or field exercises conducted by other agencies. Three different workgroups were formed to develop materials and identify staffing need for 1) conducting an epidemiologic investigation and preparing information about Avian Flu, 2) implementing a mass vaccination clinic for several hundred “vaccines” and 3) transporting and providing medical care for “patients” ill with Avian Flu. Each workgroup identified key elements to address, researched previously developed models and standard practices and determined a list of supplies and number and skills of staff needed for their portion of the drill. For the mass vaccination portion, neighboring health jurisdictions who conducted similar exercises before us freely shared their documents as well as tips and pit-falls learned with their experience. Experienced infectious disease faculty and staff from the California State Department of Health Services and the University of California School of Medicine provided invaluable guidance to aid in developing a model for an epidemiologic investigation based on the newly emerging Avian Flu.
As a relatively small jurisdiction with a limited grant base, we did not plan enough lead time to recruit evaluators nor identify extra funding for evaluation services. We did distribute written evaluations for all staff and volunteers and offered incentive “thank you” gifts at the end of the exercise to encourage a good response to these evaluations. In addition to the immediate de-briefing, we set up several small focus group meetings with assigned “observers”, exercise coordinators and “lead” staff during the three weeks following the exercise. In January and February 2004, the health department bioterrorism and emergency planning team prepared an on-line computer training had conducted a staff workshop on public health roles and responsibilities in the event of a disease outbreak. Staff comments after the trainings indicated that, although they had a better understanding about the role of public health, they were still unclear about their specific roles in the event of a disease outbreak. The public health nurses specifically requested training for their investigative role. Immediately after our Avian Flu Disease Investigation and Mass Vaccination Drill in June 2004, the health department staff overwhelmingly indicated a good or very good understanding of their role in the event of a disease outbreak. WORTH THE RESOURCES?: Yes. Across the board, the great majority of agency staff who participated in the Avian Flu Drill felt the training was positive and the practical experience for planning and practice was invaluable. The supervisory staff requested that this be done annually. Because of the enormous staff time and resources, our department decided to conduct a full scale, multi-agency local drill every other year but to support Lead Staff annually to travel to participate in similar exercises by other partner agencies. UNINTENDED CONSEQUENCES: The working relationships and regular communications established during the planning and implementation of the Avian Flu Drill have been greatly enhanced and continue nearly a year later. We also were unaware of the impact of a very visible field exercise as an educational opportunity for our elected officials, other non-medical emergency partner agencies and the public at large. The only negative consequence was some disappointment among the hospital and clinic staff that they had not planned for more patients to arrive at direct care medical sites in order to better test their capacity to respond to infectious disease outbreaks. We were also much more aware and somewhat shocked when we realized the gaps and challenges that still need to be addressed. ACHIEVED GOALS? Yes. Our main purpose was to train our staff in a multi-agency response to a disease outbreak. Overwhelmingly, the evaluations indicated that most participants gained greatly in participating in the exercise. We exceeded our objectives with the extra effort and training we spent on learning about an emerging disease and the new challenges that will bring. We found that some of our partner agencies who were not as involved in the planning, would have liked to have played a bigger role in the exercise in order to train their own staff. We also identified training needs which we are trying to address this year.
SustainabilityThe majority of agencies who committed staff time to this exercise have similar requirements to ensure an effective and well-trained response to disease control or emergency medical response and are committed to participating in annual training exercises. Federal funding from CDC, HRSA, EMSA and ODP for bioterrorism and emergency preparedness is expected to continue and be distributed to local public health and emergency response agencies. Collaborative, multi-agency full field exercises have been given high priority in these BT grants. Key Elements ReplicationElements to Replicate: case and contact tracking forms, interviewing forms, understanding of epidemiology of communicable diseases, recommendations for treatment, isolation, and quarantine, infectious disease precautions, collaborative planning, and implementation.