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CDC Live Pandemic Exercise Day I

by: DemFromCT

Tue Mar 11, 2008 at 19:51:16 PM EDT

A few days back, I wrote about a live exercise CDC was conducting, with this starting point:
A 22-year-old Georgetown University swim team member just back from Indonesia eats dinner with his teammates but then develops a fever and doesn't accompany them to a meet in New York.

That is how a flu pandemic in the United States started.

It's now six days into the scenario, there are confirmed positive cases of H5N1 in 9 states as well as the District of Columbia, and the Navy has ships off of Guam with more cases.

In addition to the 276 US cases (27 deaths) there are at least nine other countries, but none with as many confirmed cases as the US. The 10-12% CFR is seen everywhere.

The virus appears to be closely related to or descended from clade 2.1 in Indonesia, and genetic analysis suggests sensitivity to oseltamivir and adamantanes, but it's still too early to know about clinical response to these drugs.

It's 7:30 am, and the CDC Director is conducting an executive briefing to fill knowledge gaps, and plan the day's activities.

DemFromCT :: CDC Live Pandemic Exercise Day I
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).

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thank you, Dem for your report
very interesting.  Looking forward to the rest of it.  

One question, does the exercise continue round the clock?  Thanks!  

All 'safety concerns' are hypothetical.  If not, they'd be called side effects...

yes, 60 hours straight
in 12 hour shifts.

There's a time zone shift as the night crew concentrates more on overseas. State reports dry up overnight.

[ Parent ]
Round-the-clock round-the-world blogging will happen too.
I wonder what newshounds have to say about this ("round the clock blogging").  A conceptual exploration by those with the experience (aka "experts") would be most welcome.

Along a related line, I finally made a contact within InSTEDD, in case that's useful.  I think the possibility of helping newshounds innovative works, taking it to a much higher scale if and when needed, is at least intriguing.  Or maybe there are other ways to do that.

Thanks for the report, Dem.  Really looking forward to more news from the frontline, thanks!

You arm yourself to the teeth just in case.  You don't leave the gun near the baby's hand.

[ Parent ]
Reports dry up at night

 Correct me if I am wront but from personal experiance there seems to be an after dinner crowed, midnight crowed and 2am (thats when our bars close) crowed.

  As people get sick I see the after dinner crowed comming in till about midnight - then things dying down for the first day or two.

 After Day+2 hospitals might be overwhelmed with people and those working the night shift preping for the next day. Who they got in contact with, what they need, stuff that did not get reported during the day, etc.

  In my opinion, the news networks will not let this rest. Parents may find a coughing child at 3 am and panic.


[ Parent ]
much of CDC's info comes from the states
and when their offices close down, info is scant.

Night time is a good time to catch up with WHO and other time zones.

[ Parent ]
is it similar to the movie last year ?
Just more statistics, not so much picking of some
special individual cases as is done in movies.

ask experts for their subjective
panflu death expectation values
and report the replies

all stats
no individual cases.

[ Parent ]
Layman's thoughts

 Hi. Thank you for the long post.

 "EOCs in any incident, even one as complex as this, tend to look, feel and act similarly." I hope the EOC folks got to know each other with some friendly rapport as they will be trusting each other during a real pandemic.

  I  know information must be collected at each EOC/PH outfit relayed up through multiple chain of command through multiple departments to the CDC, a descision made, then confirmed and then instructions sent back down to the EOCs in order to keep everyone sycronized.

 Yet, this was the bane of American war for Independence. The long time delay allowed the colonists time to move before the orders or supplies came back. This also happened in Gult War II but that was a 'micro management issue'

 Hopefully teh CDC sees what type of Google tools are available so remote offices input data and it shows up on the screen at the CDC and other EOCs.

  I guess the scenario of citizens being passive and going along with instructions was the norm. No bad information or quackery. No allagations of "its a virus by the military to (__fill in blank one _) this group of  (__fill in blank 2 __)."  

  The scenario does say "the people are uninformed." DemFromCT has there been any talk of runninga scenario where the people are informed?? To show one scenario may be better than another?  

  Actualy I guess not. Sigh. It is safer to assume the public is uninformed and it would be hard to have confidence in a model where they where informed.

  Hats off to their work.


Another possible scenario to add
Has anything been mentioned, in this excercise, of how infrastructure and business may be affected as time goes on? ie: utilities, work-at-home parents, etc. Not just focusing on the "present", but on the short-term future of a first or second wave and it's effects on society as a whole...

Thanks for your involvement in this...great job!

it depends on how the exercise is structured, I guess
if they are starting from Day 6 and then up to 60 hours beyond, you may not be seeing much infrastructure effects at all.

Plus infrastructure is not the domain of CDC.  I don't know how involved the DHS is in this exercise.

All 'safety concerns' are hypothetical.  If not, they'd be called side effects...

[ Parent ]
it's actually difficult for CDC to explain during the exercise (that they're doing a CDC exercise) but even at the mock beiefings, they are handling questions best asked on HHS, NIH and DHS (for example, vaccine production and capability). If they are asked, they answer, but some decisions (for example, vaccine allocation when available) are not really theirs to make.

And you're right, 7 days into the pandemic with scattered cases is not when you'd see infrastructure collapse.

[ Parent ]
great Dem
Really great work Dem.

Ask the hard questions will ya????

Tell the truth


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