|The above is how the day started, with more than 100 CDC employees in the Emergency Operations Center supporting the live exercise, and around a thousand CDC personnel expected to be involved by the end of the exercise two days hence.
Naturally, the topic itself (a theoretical H5N1 pandemic) is of interest to us. What makes this event so intriguing, however, is the effort to make the exercise as realistic as possible, given all of the uncertainties that the subject brings. Given the early date (day 6), with no idea as to whether containment efforts would succeed, what the final CFR would be, whether the virus would stay susceptible to antivirals, and with full realization that most people had not prepped and that no vaccine would be available (an assumption of the exercise was that pre-pandemic vaccine was a poor match for the actual pandemic virus, so no decision to deplay had yet been made), decisions on staffing and deployment of antivirals still have to be made (thus early on, there's still enough staff, stuff, and space to deploy and plan for, though that probably won't be true later on).
EOCs in any incident, even one as complex as this, tend to look, feel and act similarly. There's an incident manager, section chiefs, planning personnel and communications staff, with the size of the entire staff expanding to fit the response. There are live reports coming in throught the day, some via media, and some unconfirmed. There are internal questions about policy, procedure and resources that need to be routed to the correct section (be they legal, infection control, quarantine or health care issues).
The CDC was very accomodating in allowing the observers access to senior staff and section officers on duty, including sitting in on an hour briefing/conference call with the affected states (whoever played those roles, the accents were perfect - Arkansas sounded nothing like Michigan). States had varying ability to update CDC with real time case numbers ("I'll get back to you on that" must have been the most commonly heard line of the day"), and difficulty with adjusting on the fly to requests for extra personnel ("we need you to send 20 staff, varying qualitications, to support screening activities at your state's busiest airport") and rapidly changing policy requests. That was especially evident when the states were asked to consider community mitigation strategies including student dismissal. Some states pushed back on that, with an observation that it would be a) difficult b) disruptive c) expensive. In addition, in some states, there was no clarity as to whether decisions would be made at the local, county or state level (states with only a few cases were less ready to pull the trigger; Hawaii was quite worried about the effect of all this on the tourist industry).
[Remember, the above is role playing, but very realistic role playing. Some states might be more ready, some states less. If they wanted to make a point in the exercise that states were not ready to simply throw a switch and turn on non-pharmaceutical intervention, practice social distancing, close schools, etc, on a moment's notice on a call from CDC,that point was made.]
Two mock press conferences were held, with the am conference focusing on the situation awareness summary, and the afternoon conference focusing on the ability to collect case reports, process them, and turn the numbers around for the press. This was also an especially interesting piece because early on confirmed cases appear as a fixed and hard number, whereas, just in seasonal flu, as the number of cases goes up the exactitude fades. Every new case isn't tested when there's many cases in the community, and the difference between 5 and 105 cases is huge, while the difference between 14,700 and 14,800 cases meaningless.
Another example of a tough question CDC needed to wrestle with is how to reroute air traffic to maximize screening efficiency. For example, in the scenario, Hawaii, Puerto Rico and Alaska were virus-free today. Would routing air traffic to a single airport in those states and territories allow better screening of passengers via health questionnaire and secondary screening va examination to delay virus appearance? That's what the extra personnel discussed above were for. Since we know screening isn't perfect, would the suggestion be helpful (too early to tell) and would /could it be complied with by the states asked to do so (also too early to tell)? Identification of further resources for the states in terms of clinical case definitions, pre-written policy on community mitigation, legal advice on voluntary (again, that's voluntary) quarantine, etc also were shared with states.
Looking to its own surge capacity, efforts were made to stay in touch with Georgia emergency managers to get a sense of whether Georgia schools would close (in the scenario, Georgia had 9 confirmed cases and one pediatric death), and what the impact would be on CDC personnel (I can only hope everyone does the same where you work).
For everyone involved, this was a seriously taken exercise, with excellent points brought up (role played or not) about such things such as the trigger for school closing and difficulty of implementation. Exercises like this often raise as many questions as they answer, and so far this appears to be the case (and that is considered a success - exercises that go perfectly are hardly worth running, because nothing works like that in real life).
I would like to thank CDC for inviting the blogging community to take part (another day to go, no idea what happens tomorrow). They're aware of who we are (the greater community beyond just Flu Wiki) and what we do. We had opportunities to ask questions all day from everyone participating about what they were doing and why - annoying for the folks trying to do their jobs, but necessary for us. I especially got to ask questions of the patient officers at the stations monitoring health care, infection control, quarantine efforts and vulnerable/special needs populations. Hopefully some of the questions I asked about their activities will bring home local needs to the folks doing the planning.
By nature, this was a CDC-centric exercise more attuned to response than to prep work; in real life, there'd also be liason work to do with HHS, DHS and the WH (many agencies had liasons staffing the EOC, so rapid contact could be made at need with State, Transportation, Commerce, etc), and there'd be PFOs and FCOs (see national response framework for definitions) to work with as well. Larger cross-departmental exercises practicing unified and joint command is another topic for another day.
All in all, a fascinating and exhausting experience. Let's do it again tomorrow. And when this one is done, planning for the next one can commence.
(Look for CIDRAP to post their perspective in the next few days).