Bio-Security 2007 Table Top Exercise in JAPAN Lessons from the Exercise Presented by Mitsuyoshi...

Bio-Security 2007Table Top Exercise in JAPAN Lessons from the Exercise

Presented by Mitsuyoshi Urashima MD, PhD, MPH

scene

Central Government(observer)

M. Health*1Foreign Affaires*2

Police*4

Defense*3

Infectious disease*10

Local Government*8

Media

Central

overseasCDCWHO:

Public health center*9

BusinessAirportAviationRailroad CoSubway CoAmusement ParkHotelsPharmaceutical Co.Travel agencyDepartment store etc

Transport*7

Hospitals First respondersFirePolice

Japanese Embassy in foreign countries

200 personnel: Not only LE/PH but Others

School

Control Room

Live Broadcasting

Mes

sen

ger

s

Hospital A Pharmaceutical Co

M of HealthNIID

Foreign Affairs

DefensePrefecture Tokyo

PH centerFire Dep

Media

AirportAviation

Transport

Tokyo Disney LandHotelTravel agency

Hospital B

Hospital C

Police

Prefecture ChibaPH centerFire Dep

Phone Phone

On the same floor15 small rooms: Each organism1 large room: Monitor and Control

Interview

No noticeReal role playPlayer drivenInjectLive broadcasting

monitoringall rooms by videorrding


CO2 incubator for Cell culture

Clean bench

Culture media

Scenario: opened to participants after exercise and before workshop

SARS virus: CDC category C

Anthrax: CDC category A

Earth Earth UndergroundUnderground

TUSK on the EarthTUSK on the Earth

Arrival: Two tourists were infected here and each visited hospital A and hospital B.

Departure: One tourist was infected here and got sick in Singapore.

This fish market was a target by terrorist.

Taking antibiotics, another taking sprayed anthrax

Many workers got inhalation anthrax by exposure to the spores at the fish market. Moreover, a person who never visited the fish market got intestinal anthrax by eating fish traded there.

Injecting InformationMinistry of Foreign Affairs

Sep 17: Anti-globalization activist: plan for demonstration by extremists during G8 Tohyako summit, by the Japanese Embassy in Germany (telegraph) FALSE

Sep 19: Extremists: possibility of bioterrorism in Japan, by the Japanese Embassy in Afghanistan (telegraph) FALSE

Sep 23: Vials containing SARS virus derived from super spreader kept in a research institution were stolen: still possibility, by the Japanese Embassy in Singapore (telegraph) TRUE

Sep 23: A Japanese tourist admitted to hospital due to severe respiratory disease, by the Japanese Embassy in Singapore (telegraph) TRUE

If these information were passed to Ministry of Health, it could be easier to suspect SARS but not avian flu.

Injecting InformationNational police agency

Sep 17: The same threatening letters by genuine defense/animal liberation fighters: “TUSK on the Earth” were sent to three fish food restaurants: Warning blast: The cancellation stamp was Toronto, Canada. TRUE

Sep 20: Threatening letter to sports stadium: Which was confirmed as cat copy of “TUSK on the Earth”. FALSE

Sep 22: Advance warning : Death to the Minister of Agriculture, Director-General of Fisheries Agency, and Minster of Environment to each major media by fax. TRUE

scene


M. Health*1 Foreign Affaires*2Police*4

Defense*3


Prefectural Government*8

MediaAvian FluOutbreaksIn Indonesia

Central

overseasCDCWHO: Avian Flu: Considering up-phase from 3 to 4 in Indonesia



Transport*7


Index case AB from Indonesia

Hospital AHospital B


Threat of terrorismRobbery of SARS vials

Injecting InformationUniversity Hospital A

Sep 17: A Japanese branch manager (62 years old male) in Indonesia had returned to Japan at September 11th, and signs of influenza like illness progressed. Although he had been followed as common cold by a family doctor, his condition was getting worse and he became aware of dyspnea. Then, he admitted to University Hospital A. He died at September 21st, and the diagnoses were non-specified pneumonia plus cardiac failure. Sep 23: First patient’s son (28 years old male), who stayed and cared his father at the hospital A, got similar symptoms, and visited ER of the hospital A with his sister (26 years old, female), who had sometimes cough. Because all the beds were occupied of the hospital A, he needed to stay at ER for overnight. He was treated with oxygen, inhalation and drip infusion.

Index Case

Son of index case

Pat 1（ 62Y ）

Pat 2（ 60Y ）

Pat 8（ 7 ８Y ）

Pat 7（ 37Y ）

Pat 3（ 28Y ）

Pat 5（ 24Y ）

Pat 6（ 27Y ）

Pat 4（ 26Y ）

Nurse: Contact with pat 3 & pat 4 at the hospital

Patient:Contact with pat 2 at ER

Visit Family A

9/13 onset9/21 death

9/21 onset9/26 death

University Hospital A

9/28 onset

9/26 onset

9/23 onset 9/23 onset

9/22 onset

infant

Wind Tower

Family A

Injecting Information

Ref. N Engl J Med. 2003 May 15;348(20):1995-2005.

Pat 1Male 35Y

death

Pat 2Female 32Y

Pat 3Female 32Y

Nurse

Pat 4Male 70Y

Wife

Contact at waiting room of hospital B

Staying at the sameFloor of the same hotel

Pat 5Female 33Y

Nurse

Pat 7Female 47Y

Nurse

Pat 6Female 38Y

Nurse

Pat 8Female 54Y

Nurse

Pat 10Male 56Y

Pat 9Male 50Y

Care pat 2 at ICUfor 6 hours

Care pat 4 at bedside

Met pat 4 at hotel and hospital

Same clinical ward with pat 4

University Hospital B9/17 onset9/21 death

9/21 onset

9/25 onset

9/21 onset

Injecting Information

Ref: N Engl J Med. 2003 May 15;348(20):1977-85.

Tokyo Disney Land

ship is available

but takes long time to reach,

Hotel

Narita International Airport

Singapore

All over Japan

Clinic

A Japanese tourist

An Indonesian tourist

Exposure

Exposure

Exposure

HospitalsExposure

Mikura island

where far from main island

do not have airport

but heliport.

愛

愛

High school

Wind Tower

Wind tower

Ho

sp A

Junior High school

Elementary school

University Hospital A

Injecting InformationTokyo prefecture

Sep 20: Phone call from a doctor of Mikura island: 6 family members have got serious pneumonia who came back from Tokyo Disney Land. 7 neighbors started fever and cough, still not serious yet. Carrying these patients by ship is danger and would you consider sending a helicopter?

Sep 24: Phone call from health consulting office at Wind Tower with 42 stories: 5 residents are state of respiratory distress. All hospitals nearby rejected due to no beds available. Would you seek hospital beds for us?

Sep 25: Phone call from health consulting office at Wind Tower: We’ve got a problem. Many of residents are complaining high fever and dyspnea. They have little connection within the Tower, thus infectious agents were disseminated through air. We have approximately 700 residents in this Tower and 10% are now sick, which is more than 10 times of yesterday.

Tokyo prefectural government

Influenza in IndonesiaPandemic? News

Threat letter against fish food shop

central gov.

Local fire department

Anthrax case in Hosp C: News

Pneumonia outbreak at Mikura IslandFrom Tokyo Pref.

Local public health

Chiba PrefAnthrax?

Central Gov.

Suspect Avian Flu

MikuraDispatch staff

Governor appealed Self-imposed control

Department store

Japan Rail

Media

Fire department

Hospital B: Need more staff

Ministry of Health

Wind Towerquarantine

Self-Defense Forces

Helicopter

Outbreaks in Hosp A, B and Wind Tower: News

Central Gov.

Dispatch medical staff with helicopters of self defense forces to Mikura: Consider quarantine whole island

central gov.

Media

Media

Office of Emergency Management

Overt terro

愛

愛

High schoolWind Tower

Hospital

Local

government

Quarantine

Quarantine as

a whole island

Tower

Injecting InformationDistrict General Hospital C

Sep 17: 72 years old male transferred to ER of District General Hospital C by ambulance for fever, chest pain in swallowing and dyspnea. The diagnosis was mediastainal abscess, of which chest x-ray findings are similar to those of inhalation anthrax. Players of hospital C did not showed any reactions to this case.

FALSESep 19: 56 years old fisherman visited for District General Hospital C for fever, cough and dyspnea. Players of hospital C did not showed any reactions to this case, too.

TRUE

Sep 22: Phone call from laboratory: Gram positive rods were detected in spinal fluid and blood of second patient, suspecting Bacillus Anthracis. Although the appearance of the organism was certainly consistent with another bacillus species, such as B. cereus or B. subtilis, these pathogens would not have been expected to be found in an otherwise healthy man. Thus, the case of fisherman was suspected inhalation anthrax and hospital C informed it to a local

public health center. Index case’s wife and five other patients who were in the fish market at 9 11th visited the hospital for

respiratory symptoms.

Injecting InformationDistrict General Hospital C

Sep 23: Results from drug sensitivity analysis phone and fax by laboratory.

Cipro and penicillin were sensitive.

Sep 25. 25 years old male visited the hospital for abdominal pain and distension. 10 days ago, he ate fish meat bought at a fish shop, but never been to fish market. After operation, he recovered. His diagnosis was confirmed as intestinal anthrax.

Ciprofloxacin <0.06*Rifampin 0.5*Tetracycline 0.06*Vancomycin 1-2* Penicillin <0.06**Clindamycin <0.5*Chloro 4*

This episode suggest that fish meat traded at the fish market September 11th is a risk for intestinal anthrax. All the fish meat should be traced and if it is too late, someone has to decide whether antibiotics are distributed to the people at risk as a post exposure prophylaxis and what extent.

Scenario of Anthrax attack

Hospital C

Public health side Law enforcement side

Local public health center

Prefectural government

Ministry of health

Local police office

Prefectural Police: NBC unit

National police agency

central gov.

Media

Expected: Observed:

offer

accept

pharmaceutical company

Chiba prefectural government

Influenza in IndonesiaPandemic? News

Threat letter against fish food shop

Local public health

Local police office

Anthrax case in Hosp C: News

Travel agency

Media

Pneumonia outbreak at Mikura IslandFrom Tokyo Pref.

Local public healthHotelHospital B

Local public health

Disney LandMinistry of Health

Mayor of city

Recognized Anthrax

Hospital B

Recognized outbreak of unknown origin:Suspect Avian Influenza

Media

Office of Emergency Management Media

Local police officeDispatch NBC unit

Media

Stadium: white powder

Fire department

Hospital B: Need more staff

Ministry of Health

Local police officeDispatch NBC unitDecontamination

Self-Defense Forces

Ministry of Healthcentral gov.

Recognized SARS

Local public health

central gov.

DMAT

Fire d

Tokyo

A secret base of terrorist: News

Overt Terrorism

Press Conference

central gov.Ministry of HealthMinistry of Foreign AffairesMinistry of internal affairs and communications

MediaJournalist

Live broadcasting

Terrorist group: earth underground; “TUSK on the Earth” declared bioterrorism using SARS virus and anthrax, which included information known only by criminals.

scene

Central Gov


Defense*3



Media

Central

overseasCDCWHO:



Transport*7



Epidemic of SARS

We’ve got a problem.

Hospitals are critical.

Nosocomical InfectionMaybe….

Outbreak of respiratory disease caused by unknown origin

Process Information Degradation of Information: SARS case

scene

Central Gov


Defense*3



Media

Central

overseasCDCWHO:



Transport*7



Epidemic of Anthrax

We have many patients with anthrax. They can be exposed to anthrax spore at fish market.

There are many patients with anthrax.

Perhaps, some patients are suspected anthrax.

There are patients with anthrax.

Process Information Degradation of Information: Anthrax case

Process Information

Doctors tended to

1) concentrate their attention on diagnosis and treatment of patients: do not know what’s going on in surrounding area and nation;

2) do all operations by themselves: do not ask for help;

3) do not have press conference.

Hospital

Prefectural

government

Mass patients transfer

WHICH?Island

Tower

Process information: Media: Panic: Crises at hospitals: Mass patients transfer: Therapeutic priorities: Post exposure prophylaxis: Leadership:

Lessons from the Exercise

Bio-Security 2007 Table Top Exercise in JAPAN Lessons from the Exercise Presented by Mitsuyoshi...

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Transcript of Bio-Security 2007 Table Top Exercise in JAPAN Lessons from the Exercise Presented by Mitsuyoshi...