2006 Great Lakes Border Health Initiative Conference August 25, A Collaborative International Border Exercise: Viral Hemorrhagic Fever

Transcription

1 2006 Great Lakes Border Health Initiative Conference August 25, 2006 A Collaborative International Border Exercise: Viral Hemorrhagic Fever SITUATION MANUAL Michigan Center for Public Health Preparedness Office of Public Health Practice University of Michigan School of Public Health 109 Observatory Street, Ann Arbor, MI prepared@umich.edu, This project is funded by a Cooperative Agreement from the Centers for Disease Control and Prevention, number U90/CCU , and by the New York State Department of Health, contract number

2 TABLE OF CONTENTS Subject Page Introduction...2 Exercise Schedule...6 Module 1 Scenario Introduction...7 Module 2 Scenario Update...11 Module 3 Scenario Update...16 Evaluations...18 Appendices Appendix A Reference Map I... A-1 Appendix B Reference Map II... A-2 Appendix C Viral Hemorrhagic Fever Fact Sheet... A-3 Appendix D Lassa Fever Fact Sheet... A-5 Appendix E Event Timelines... A-6 Appendix F Excerpt from Great Lakes Border Health Initiative Public Health Emergency Communication Guideline (Draft)... A-9 1

3 INTRODUCTION Purpose The purpose of this exercise is to: Test the ability of Michigan, Minnesota, New York, Wisconsin, Ontario, and border tribes/first nations to respond to a cross-border public health emergency involving viral hemorrhagic fever. Provide exercise participants an opportunity to test existing communicable disease protocols. Identify gaps in cross-border communications plans. Scope This exercise emphasizes the cross-border communications and information sharing processes in response to the potential consequences of a communicable disease emergency. Processes and decision making are more important than minute details. Design Objectives At the completion of this exercise, the participant will be able to: Demonstrate cross-border crisis communication skills utilizing formal mechanisms described in the Great Lakes Border Health Initiative Public Health Emergency Communication Guideline. Identify the necessary steps to initiate surveillance and outbreak control processes in a cross-border communicable disease emergency. Organize community containment response efforts between local, tribal/first nations, state/provincial, and federal agencies. Demonstrate appropriate response for regulating movement across the Canadian-US border during a communicable disease emergency. 2

4 Exercise Structure This will be a multimedia facilitated Tabletop Exercise (TTX). A TTX is a discussion-based activity designed to assess plans, policies, procedures or other preparedness measures through facilitated group discussion and problem-solving. Participants may include key personnel from one or multiple agencies, disciplines, sectors or jurisdictions. This exercise is conducted in a relatively informal, low-stress setting, and play focuses on a variety of issues raised by the presentation of a simulated or hypothetical, but realistic, situation. Tabletops are designed primarily to test or assess existing plans, procedures and systems. They also build or enhance teamwork, essential relationships, communications networks, self-confidence and competence, and interagency or multijurisdictional coordination all before disasters strike. Exercise Format Participants will respond to the following scenario modules and accompanying discussion questions: Module 1 Scenario Introduction Module 2 Scenario Update Module 3 Scenario Update Each module begins with a situation briefing or update presented to the plenum. Following each module briefing, players, who have been organized into groups, will discuss key issues within their group. For this exercise, the groups will be based on geographic location and jurisdiction. The facilitator may also provide additional updates throughout the modules along with added questions. Following each situation update, players will utilize a caucus period to review the module and discuss the questions at the end of each module as well as the response issues relevant to their group. Players should feel free to ask questions of other groups. At the conclusion of each small group discussion period, the facilitator will call on persons from select groups to present a synopsis of the group s discussion, issues, and recommendations. Roles and Responsibilities Players respond to the situation presented based on expert knowledge of response procedures, current plans and procedures, and insights derived from training and experience. Facilitators provide the purpose and objectives for the tabletop exercise. They orient participants to the exercise design, timelines, format, and supporting materials. They also explain the various 3

5 roles, responsibilities, and expectations of all participants, and present the scenarios. Facilitators keep participants on task and on time, and conduct post-exercise reporting and debriefing. Co-facilitators assist the facilitator with duties. Table Leaders keep their individual group on task. They facilitate group discussions by, engaging all table participants in the process. They also report back about the group discussions to the facilitator. Table Recorders take notes of group responses to discussion questions. They organize and summarize group responses for reporting purposes, and they provide notes to the evaluator at the end of the exercise. Evaluators will not participate in the discussion periods, but will be present for the duration of the exercise to identify the strengths, weaknesses, and unanticipated responses to the tabletop. They are responsible for observing and recording the level of participation, body language, amount of delegation, group process, and ability to stick to the task. Evaluators identify communication problems along with consistency/accomplishments with objectives of the exercise. This information is compiled into the exercise After Action Report (AAR), for which evaluators are also responsible. Assumptions and Artificialities In any exercise, a number of assumptions and artificialities may be necessary to complete play in the time allotted. During the exercise, the following apply: The scenario is plausible, and events occur as they are presented. There are no hidden agendas or trick questions. All players receive information at the same time. Exercise Rules There is no school solution. Varying viewpoints, even disagreements, are expected. This is intended to be a safe, open, stress-free environment. To the extent possible, you should assume the actual role or position you would have in a real public health emergency. However, if your group does not include a key official from your agency or jurisdiction whom you feel would be essential in an actual event, you may need to play a dual role and project their role or perspectives as needed, within the limits of your familiarity with them. Some of you will also have the special roles of leader or reporter for your group. 4

6 Feel free to consult any handouts, maps or other resources provided here, or any actual plans or policy documents from your agency that you may have brought along. Remember, other people in this room can also be resources, and the various tables are not competing with each other. Don t feel that you are chained to your table feel free during discussions to get up and consult with anyone else in the room if you feel they may have some needed information or expertise. As you work through this exercise, maintain the perspective that all events have already occurred, and try to focus on the overall context of cross-border issues. You will need to reevaluate the situation, consider new data, adapt and make decisions as the exercise evolves through its progressive stages. The questions that you will discuss in your groups following the initial scenario and subsequent updates are intended to focus your discussions and draw out key points. It is not required or expected that you will answer every question or sub-question. The goal here is not to answer every question in the time available, but to engage in productive discussions. You may resolve some issues, but raise others, and that s fine. Maintain an open mind and respect for different views or interpretations. Only one person within each group should be talking at a time; side conversations tend to be distracting and discourteous. Remain engaged in exercise play, and don t be afraid to offer your recommendations or perspectives. If you sit back and say nothing, the overall exercise outcome will be diminished in proportion to what you held back. At the same time, you shouldn t dominate the conversation, and should allow others to speak. Additional Resources During the exercise, you may need some specific information to assist you in making a decision. The appendices to this Situation Manual (SITMAN) contain additional information you may use in your discussion. As you participate, draw on your experience and knowledge of how various levels of governmental agencies work together in an emergency response situation. 5

7 EXERCISE SCHEDULE 10:15 Welcome and Introduction 10:30 Module 1 Scenario Introduction Situation Briefing Small Group Discussion Large Group Discussion 11:30 Lunch/Break 11:45 Module 2 Scenario Update Situation Briefing Small Group Discussion Large Group Discussion 12:45 Module 3 Scenario Update Situation Briefing Small Group Discussion Large Group Discussion 1:30 Group Evaluation 1:50 Hot Wash 2:10 Closing Comments 2:15 Individual Evaluations & Adjourn 6

8 MODULE 1 SCENARIO INTRODUCTION Module 1 In June, a World Health Organization surveillance team in Sierra Leone released a health alert about an increased number of cases of viral hemorrhagic fever (VHF) at local hospitals. Immediately, public service announcements were posted throughout West Africa where VHFs are endemic and often transmitted by local rodents. Travel advisories were issued to travelers entering the region with instructions to stay away from rodents and to report any flu-like systems to health authorities. On August 6, American Paul Chapman entered an airport in Lagos, Nigeria to catch an outward bound flight to Detroit, Michigan (via Amsterdam). After passing through airport security undetected, he boarded the plane with a carry-on bag containing 10 small and rather cute rodents, some of which he sold to pet stores in the Detroit area. He then crossed the Detroit River to attend a family wedding in Windsor, Ontario. On August 16, Paul Chapman was admitted to Windsor Regional Hospital in Ontario with persistent fever, chills, sore throat, diarrhea and back pain. On admission he was alert and had a temperature of F (39.8 C). The attending medical practitioner took Paul Chapman's blood sample for lab screening as they speculated a possible case of malaria based on his travel history. Later that day, test results ruled out malaria. Because of the travel history of Mr. Chapman, the hospital laboratory contacted the public health department. Following consultation with the epidemiologist, who had seen the WHO travel advisory for VHFs, the hospital sent the specimen to the National Microbiology Laboratories in Winnipeg to be tested for suspected viral etiologies, namely viral hemorrhagic fevers. Task Based on the information provided, consider the questions raised in Module 1. Identify any additional requirements, critical issues, decisions, and/or questions you feel should be addressed at this time. 7

9 MODULE 1 QUESTION SET 1 Review the following questions in their entirety and discuss your group s major concerns at this point in the exercise scenario. (Note: If cases are not in your jurisdiction, talk about how you would respond if they were in your area.) What facility-based disease control measures, if any, should be implemented? What population-level disease control measures, if any, should be implemented? Who should be notified of this case? o At what point should the hospital notify the health department? o Refer to the border health communication guidelines to help determine if international notification should occur. o Does anyone need to be notified at this point? What surveillance and/or epidemiologic investigations should be initiated, if any? 8

10 MODULE 1 INJECT August 17 Sarah Knolls, an emergency trauma nurse returned to her home in Buffalo, NY after a family vacation in Southeastern Michigan. By the time Sarah returned to work on August 19, she started having terrible headaches, chills, severe sore throat and a persistently high fever, 104 F (40 C). She was removed from her normal duties and admitted to the hospital. She received medical attention from her colleagues who used minimal personal protective equipment while caring for their co-worker. August 19 After ruling out several probable causes, Sarah's physician contacted the health department to discuss other probable etiologies. They came to the conclusion that the cause of Sarah's symptoms was likely viral, therefore the blood work was sent to the state public health laboratory in Albany, NY. At the same time, local Buffalo educational officials became alarmed when Sarah's son, along with twenty classmates, began showing similar symptoms. The local health department was notified and the state health department and CDC were consulted. 9

11 MODULE 1 QUESTION SET 2 Review the following questions in their entirety and discuss your group s major concerns at this point in the exercise scenario. What facility-based disease control measures should be implemented? What population-based disease control measures should be implemented or considered? What disease control measures should be implemented by the school? With cases of an unknown disease occurring in a school, the media will quickly learn about the situation. What should you do to deal with the media? Who needs to be notified (even though a diagnosis has not been made)? o Refer to the border health communication guidelines to help determine if international notification should occur. If so, what agency? Is this a communicable disease emergency? What kind of investigation (if any) should be done? o Consider period of communicability and incubation period to determine which population is at greatest risk. What types of surveillance data would be useful at this point in time and how would you use these data? 10

12 MODULE 2 SCENARIO UPDATE Module 2 By the evening of August 20, preliminary diagnostics, using the polymerase chain reaction (PCR), for the clinical specimen that was sent to Winnipeg indicated that Paul Chapman was infected with Lassa fever. Because of the danger of working with BSL 4 agents, confirmatory tests were not run. After receiving specimen from the New York state public health lab, the CDC diagnosed Sarah Knolls'and other suspicious cases in Buffalo as having Lassa fever on August 24. Health officials in both countries began emergency investigations to identify other suspected cases and the cause of the outbreak. At this point, several international news agencies began reporting a deadly outbreak sweeping across Canada and the United States. While attempting to contain wide-spread panic, Canadian officials discovered that Paul Chapman was an exotic animal trader who sold multimammate rats of the genus Mastomys a reservoir host for Lassa fever to pet stores in the United States. Sarah Knolls told health officials that the onset of her symptoms began after purchasing one of these rodents from a pet store in Michigan, which she gave to her son as a gift. The Ontario Ministry of Health found a total of 80 persons had contact with Paul Chapman and/or his rats during the period when he was likely infectious; of those, 38 persons were classified as at high risk and 42 as low risk. The high risks included his cousin Laura, Laura's children, and several family members in town for the wedding; each reportedly had played with the rats. Contacts at low risk included others who attended the wedding, and 14 health-care workers employed at the Windsor Regional Hospital (including 3 laboratory workers, 9 nurses, and 2 physicians). By August 25, 60 case-patients were suspected of having Lassa fever. While the New York Department of Health investigated the Buffalo cases, the Michigan Department of Community Health and the Detroit Department of Health and Wellness Promotion began receiving reports of suspicious ailments that were quickly suspected as being Lassa fever. Almost all case-patients had similar symptoms: sore throat, cough, high fever and bleeding under the skin. Between August 23 and 25, the number of new cases with similar symptoms in Michigan increased from 8 to 65, but no diagnosis was made until August 25. Preliminary investigations identified a potential link between case-patients and two Detroit-area pet stores, which purchased rodents from a man matching Paul Chapman's description. 11

13 It was also discovered that some of the rats were shipped to other pet stores in Minnesota and Wisconsin. Curiously, health care providers in these two states had not reported any suspected cases of Lassa fever. Task Based on the information provided, consider the questions raised in Module 2. Identify any additional requirements, critical issues, decisions, and/or questions you feel should be addressed at this time. 12

14 MODULE 2 QUESTION SET 1 Review the following questions in their entirety and discuss your group s major concerns at this point in the exercise scenario. Who is the incident commander? What can Minnesota and Wisconsin do to prevent the spread of Lassa to their jurisdiction? (Consider which agencies will be involved with these decision processes: disease control measures, communication strategies, surveillance activities, and movement restrictions/ border closing) What crisis communications strategies should be considered at this point in time? Who should be notified? What cross-border communication activities should occur? How? What additional surveillance activities should be implemented? Would any of these activities be targeted to specific sub-populations? 13

15 MODULE 2 INJECT Gail Brown from Minneapolis, Minnesota and Kris Wilder from Madison, Wisconsin recently purchased rats at their local pet stores. Ironically, these rats were acquired from the same distributing pet store in Michigan seven days prior. Within two weeks of their purchase, Gail and Kris began having similar symptoms and were admitted to local hospitals. Later, several Minneapolis medical practitioners who attended to Gail developed severe abdominal pain, diarrhea, chills and fever. Laboratory results lead to the diagnosis of Lassa fever for Gail Brown, and subsequently the medical practitioners were diagnosed as having Lassa fever as well. Fifty other cases in the health systems were found by September 1 when health departments contacted local physicians throughout each state. 14

16 MODULE 2 QUESTION SET 2 Review the following questions in their entirety and discuss your group s major concerns at this point in the exercise scenario. What might explain the delay in case reporting in these states? How do these delays impact response activities? Discuss the communications issues that are occurring across the border and how? Should any restrictions be placed on the movement or importation of animals across borders? How does the veterinary community and regulators fit into this investigation? Where does the agriculture department play a role? Who has jurisdiction over these contaminated rats? 15

17 MODULE 3 SCENARIO UPDATE Module 3 Two Months Later For the first time since cases of Lassa fever were diagnosed, health officials noted a decline in the number of new cases, and most case-patients had returned to relatively normal health status. During the process of controlling the outbreak, several restrictions were placed on the affected population including: Restrictions on work and travel for asymptomatic adults at high risk of developing Lassa fever Monitoring of people at relatively low risk in order to rapidly detect new cases Restriction of the children of case-patient from participating in school activities Administration of massive amounts of Ribavirin to patients Cross-border movement restrictions Closing of schools, businesses and restrictions on social gatherings in some situations Health officials were relieved their efforts to curtail Lassa fever had eliminated a potentially explosive pandemic of viral hemorrhagic fever throughout North America. However, health departments will be dealing with the long term effects of Lassa for quite some time, which include the complication of deafness affecting 25% of the Lassa fever case-patients. In addition, decisions must be made about removing disease control measures in an attempt to resume to 'normal,'as local businesses are anxious to return to full-capacity in time for the holiday season. Health officials must balance economic pressures with the public's health. Task Based on the information provided, consider the questions raised in Module 3. Remember to identify any additional requirements, critical issues, decisions, and/or questions you feel should be addressed at this time. 16

18 MODULE 3 QUESTIONS Review the following questions in their entirety and discuss your group s major concerns at this point in the exercise scenario. When do you remove restrictions on movement and who decides? o Should you remove restrictions immediately or wait until there are no incident cases? When do you return to normal staffing for laboratory, epidemiology and surveillance activities? Who sets the conditions and circumstances? How do you assess the impact of this outbreak? What sorts of follow-up do you do with case-patients? o What do you do to help those who had the disease? How can we minimize this type of outbreak in the future? How can you improve your response for the future? 17

19 EVALUATIONS Group Evaluation Form Table Number Table Jurisdiction INSTRUCTIONS: The table's facilitator will lead the group in this evaluation by: Reading each activity listed in the first column of each table out loud to the group. Asking the group members to judge if the group discussed or completed the activity to some extent. By "completing the activity," we mean engaging in some activity beyond discussion such as writing, gathering information from a trusted source, or providing information to the appropriate agency. The facilitator will then summarize the group members' judgments by choosing one of the three categories that indicate the majority's opinion. CIRCLE ONE ANSWER: Activities Gather information for notifying specified individuals about the situation. Determine if a communicable disease alert should be issued to notify people within your jurisdiction. Develop informational materials for health care providers and health department use. Did not discuss or complete the activity Discussed the activity, but did not complete the activity Discussed the activity and completed the activity to some extent 18

20 Activities Prepare communicable disease alert message. Obtain approval for delivery of the alert. Send alert to appropriate health department staff and health care providers. Did not discuss or complete the activity Discussed the activity, but did not complete the activity Discussed the activity and completed the activity to some extent Designate a spokesperson. Prepare press release. Get approval for press release delivery. Monitor media for rumor control. Monitor other sources of information (CDC, WHO, Health Canada, etc.). Send information to appropriate people in other jurisdictions. Determine that a communicable disease emergency is occurring. Develop case definition for the disease/condition that is causing the emergency. Take immediate disease control measures. Conduct investigation of cases and contacts. Evaluate control strategies and modify as necessary. 19

21 Activities Confirm diagnosis in consultation with appropriate laboratories. Did not discuss or complete the activity Discussed the activity, but did not complete the activity Discussed the activity and completed the activity to some extent Identify additional cases. Use surveillance data to predict high risk areas or populations. Provide data for communications purposes. Track long term effects of disease. Determine likely modes of disease transmission. Develop situational guidelines for disease control. Identify target population for control measures. Consider isolation of ill infected cases of disease. Consider quarantine of exposed, not ill contacts of cases. Consider control of disease using biologics (medication or vaccines). Discuss movement of patients for higher level of care. Discuss the regulation of daily traffic across borders. Discuss health care workers needing to cross borders. Discuss movement of laboratory specimens across borders. 20

22 Activities Discuss advice to citizens regarding international travel. Discuss laws and authorities regarding border closing. Did not discuss or complete the activity Discussed the activity, but did not complete the activity Discussed the activity and completed the activity to some extent 21

23 Individual Evaluation Great Lakes Border Health Initiative Conference Tabletop Scenario Dearborn, MI August 25, 2006 Do you agree or disagree with the following statements? 1. The content of this tabletop exercise is relevant to my practice. 2. The method used to present the material was effective. Strongly Disagre e Circle One Answer Disagree Neutral Agre e Strongly Agree The tabletop exercise was realistic The structure of the tabletop exercise was effective. 5. The instructions for the tabletop exercise were clearly articulated by instructors. 6. The tabletop exercise was valuable for improving my skills Overall, the tabletop exercise was a valuable learning experience Describe the most useful or valuable outcomes of today s tabletop exercise. 22

24 9. How did today s tabletop exercise improve your specific knowledge or skills for managing public health emergencies? Please list the specific areas of knowledge or skill development that improved. 10. In what ways did today s tabletop exercise disappoint you or fail to meet your expectations? 23

25 11. What would have made today s tabletop exercise more successful? 12. On a five-point scale, how useful was this tabletop exercise for your work? (Circle one answer) 4 5 Not at all A little Somewhat Very Extremely Useful Useful Useful Useful Useful 13. If we offered today s tabletop exercise again in the future, would you recommend it to a colleague? (Check one answer) No Recommend with reservations Recommend with NO reservations 24

26 APPENDICES Appendix A Reference Map I A-1

27 Appendix B Reference Map II A-2

28 Appendix C Viral Hemorrhagic Fever Fact Sheet Fact Sheet from CDC What are viral hemorrhagic fevers? Viral hemorrhagic fevers (VHFs) refer to a group of illnesses that are caused by several distinct families of viruses. In general, the term "viral hemorrhagic fever" is used to describe a severe multi-system syndrome (multi-system in that multiple organ systems in the body are affected). Characteristically, the overall vascular system is damaged, and the body's ability to regulate itself is impaired. These symptoms are often accompanied by hemorrhage (bleeding); however, the bleeding is itself rarely life-threatening. While some types of hemorrhagic fever viruses can cause relatively mild illnesses, many of these viruses cause severe, life-threatening disease. How are hemorrhagic fever viruses grouped? VHFs are caused by viruses of four distinct families: arenaviruses, filoviruses, bunyaviruses, and flaviviruses. Each of these families shares a number of features: They are all RNA viruses, and all are covered, or enveloped, in a fatty (lipid) coating. Their survival is dependent on an animal or insect host, called the natural reservoir. The viruses are geographically restricted to the areas where their host species live. Humans are not the natural reservoir for any of these viruses. Humans are infected when they come into contact with infected hosts. However, with some viruses, after the accidental transmission from the host, humans can transmit the virus to one another. Human cases or outbreaks of hemorrhagic fevers caused by these viruses occur sporadically and irregularly. The occurrence of outbreaks cannot be easily predicted. With a few noteworthy exceptions, there is no cure or established drug treatment for VHFs. In rare cases, other viral and bacterial infections can cause a hemorrhagic fever; scrub typhus is a good example. What carries viruses that cause viral hemorrhagic fevers? Viruses associated with most VHFs are zoonotic. This means that these viruses naturally reside in an animal reservoir host or arthropod vector. They are totally dependent on their hosts for replication and overall survival. For the most part, rodents and arthropods are the main reservoirs for viruses causing VHFs. The multimammate rat, cotton rat, deer mouse, house mouse, and other field rodents are examples of reservoir hosts. Arthropod ticks and mosquitoes serve as vectors for some of the illnesses. However, the hosts of some viruses remain unknown -- Ebola and Marburg viruses are well-known examples. How are hemorrhagic fever viruses transmitted? Viruses causing hemorrhagic fever are initially transmitted to humans when the activities of infected reservoir hosts or vectors and humans overlap. The viruses carried in rodent reservoirs are transmitted A-3

29 when humans have contact with urine, fecal matter, saliva, or other body excretions from infected rodents. The viruses associated with arthropod vectors are spread most often when the vector mosquito or tick bites a human, or when a human crushes a tick. However, some of these vectors may spread virus to animals, livestock, for example. Humans then become infected when they care for or slaughter the animals. Some viruses that cause hemorrhagic fever can spread from one person to another, once an initial person has become infected. Ebola, Marburg, Lassa and Crimean-Congo hemorrhagic fever viruses are examples. This type of secondary transmission of the virus can occur directly, through close contact with infected people or their body fluids. It can also occur indirectly, through contact with objects contaminated with infected body fluids. For example, contaminated syringes and needles have played an important role in spreading infection in outbreaks of Ebola hemorrhagic fever and Lassa fever. What are the symptoms of viral hemorrhagic fever illnesses? Specific signs and symptoms vary by the type of VHF, but initial signs and symptoms often include marked fever, fatigue, dizziness, muscle aches, loss of strength, and exhaustion. Patients with severe cases of VHF often show signs of bleeding under the skin, in internal organs, or from body orifices like the mouth, eyes, or ears. However, although they may bleed from many sites around the body, patients rarely die because of blood loss. Severely ill patient cases may also show shock, nervous system malfunction, coma, delirium, and seizures. Some types of VHF are associated with renal (kidney) failure. How are patients with viral hemorrhagic fever treated? Patients receive supportive therapy, but generally speaking, there is no other treatment or established cure for VHFs. Ribavirin, an anti-viral drug, has been effective in treating some individuals with Lassa fever or HFRS. Treatment with convalescent-phase plasma has been used with success in some patients with Argentine hemorrhagic fever. How can cases of viral hemorrhagic fever be prevented and controlled? With the exception of yellow fever and Argentine hemorrhagic fever, for which vaccines have been developed, no vaccines exist that can protect against these diseases. Therefore, prevention efforts must concentrate on avoiding contact with host species. If prevention methods fail and a case of VHF does occur, efforts should focus on preventing further transmission from person to person, if the virus can be transmitted in this way. Because many of the hosts that carry hemorrhagic fever viruses are rodents, disease prevention efforts include Controlling rodent populations; Discouraging rodents from entering or living in homes or workplaces; Encouraging safe cleanup of rodent nests and droppings. For hemorrhagic fever viruses spread by arthropod vectors, prevention efforts often focus on communitywide insect and arthropod control. In addition, people are encouraged to use insect repellant, proper clothing, bed nets, window screens, and other insect barriers to avoid being bitten. For those hemorrhagic fever viruses that can be transmitted from one person to another, avoiding close physical contact with infected people and their body fluids is the most important way of controlling the spread of disease. Barrier nursing or infection control techniques include isolating infected individuals and wearing protective clothing. Other infection control recommendations include proper use, disinfection, and disposal of instruments and equipment used in treating or caring for patients with VHF, such as needles and thermometers. A-4

30 Appendix D Lassa Fever Fact Sheet Fact Sheet from CDC What is Lassa fever? Lassa fever is an acute viral illness that occurs in West Africa. The illness was discovered in 1969 when two missionary nurses died in Nigeria, West Africa. The cause of the illness was found to be Lassa virus, named after the town in Nigeria where the first cases originated. The virus, a member of the virus family Arenaviridae, is a single-stranded RNA virus and is zoonotic, or animal-borne. In areas of Africa where the disease is endemic (that is, constantly present), Lassa fever is a significant cause of morbidity and mortality. While Lassa fever is mild or has no observable symptoms in about 80% of people infected with the virus, the remaining 20% have a severe multi-system disease. Lassa fever is also associated with occasional epidemics, during which the case-fatality rate can reach 50%. Where is Lassa fever found? Lassa fever is an endemic disease in portions of West Africa. It is recognized in Guinea, Liberia, Sierra Leone, as well as Nigeria. However, because the rodent species which carry the virus are found throughout West Africa, the actual geographic range of the disease may extend to other countries in the region. In what species is Lassa virus maintained? The reservoir, or host, of Lassa virus is a rodent known as the "multimammate rat" of the genus Mastomys. It is not certain which species of Mastomys are associated with Lassa; however, at least two species carry the virus in Sierra Leone. Mastomys rodents breed very frequently, produce large numbers of offspring, and are numerous in the savannas and forests of West, Central, and East Africa. In addition, Mastomys generally readily colonize human homes. All these factors together contribute to the relatively efficient spread of Lassa virus from infected rodents to humans. What are the symptoms of Lassa fever? Signs and symptoms of Lassa fever typically occur 1-3 weeks after the patient comes into contact with the virus. These include fever, retrosternal pain (pain behind the chest wall), sore throat, back pain, cough, abdominal pain, vomiting, diarrhea, conjunctivitis, facial swelling, proteinuria (protein in the urine), and mucosal bleeding. Neurological problems have also been described, including hearing loss, tremors, and encephalitis. Because the symptoms of Lassa fever are so varied and nonspecific, clinical diagnosis is often difficult. Are there complications after recover? Lassa virus electron micrograph. Image courtesy, C.S. Goldsmith and M. Bowen (CDC). The most common complication of Lassa fever is deafness. Various degrees of deafness occur in approximately one-third of cases, and in many cases hearing loss is permanent. As far as is known, severity of the disease does not affect this complication: deafness may develop in mild as well as in severe cases. Spontaneous abortion is another serious complication. A-5

31 Appendix E Event Timelines Module 1 Timeline Paul Chapman catches a flight from Nigeria to Detroit with concealed exotic animals. August 6 Paul Chapman admitted to Ontario hospital with unusual symptoms. Malaria ruled out. August 16 WHO released a health alert about an increase in cases of VHF in Sierra Leone. Paul Chapman sells most of the animals to Detroit-area pet stores. August 7-13 A-6

32 Module 1 and Inject 1 Timeline Paul Chapman catches a flight from Nigeria to Detroit with concealed exotic animals. August 6 Paul Chapman admitted to Ontario hospital with unusual symptoms. Malaria ruled out. August 16 Sarah Knolls developed symptoms. Blood work sent to state lab. Sarah's son and 20 classmates show symptoms. August 19 WHO released a health alert about an increase in cases of VHF in Sierra Leone. Paul Chapman sells most of the animals to Detroit-area pet stores. August 7-13 Sarah Knolls returns to Buffalo, NY after vacation in SE Michigan. August 17 Module 1, Inject 1 and Module 2 Timeline Paul Chapman catches a flight from Nigeria to Detroit with concealed exotic animals. August 6 Paul Chapman admitted to Ontario hospital with unusual symptoms. Malaria ruled out. August 16 Sarah Knolls developed symptoms. Blood work sent to state lab. Sarah's son and 20 classmates show symptoms. August 19 CDC diagnosed Sarah Knolls and other cases in Buffalo, NY as having Lassa fever. August 24 WHO released a health alert about an increase in cases of VHF in Sierra Leone. Paul Chapman sells most of the animals to Detroitarea pet stores. August 7-13 Sarah Knolls returns to Buffalo, NY after a vacation in SE Michigan. August 17 Paul Chapman diagnosed as having Lassa fever. August suspected cases were diagnosed as Lassa fever in Canada. Number of new cases in Michigan increased to 65. August 25 A-7

33 Module 1, Inject 1, Module 2 and Inject 2 Timeline Paul Chapman catches a flight from Nigeria to Detroit with concealed exotic animals. August 6 Paul Chapman admitted to Ontario hospital with unusual symptoms. Malaria ruled out. August 16 Sarah Knolls developed symptoms. Blood work sent to state lab. Sarah's son and 20 classmates show symptoms. August 19 CDC diagnosed Sarah Knolls and other cases in Buffalo, NY as having Lassa fever. August 24 Gail Brown and 50 other cases diagnosed as having Lassa in Minnesota. Sept 3 WHO released a health alert about an increase in cases of VHF in Sierra Leone. Paul Chapman sells most of the animals to Detroit-area pet stores. August 7-13 Sarah Knolls returns to Buffalo, NY after a vacation in SE Michigan. August 17 Paul Chapman diagnosed as having Lassa fever. August suspected cases were diagnosed as Lassa fever in Canada. Number of new cases in Michigan increased to 65. August 25 Module 1, Inject 1, Module 2, Inject 2 and Module 3 Timeline Paul Chapman catches a flight from Nigeria to Detroit with concealed exotic animals. August 6 Paul Chapman admitted to Ontario hospital with unusual symptoms. Malaria ruled out. August 16 Sarah Knolls developed symptoms. Blood work sent to state lab. Sarah's son and 20 classmates show symptoms. August 19 CDC diagnosed Sarah Knolls and other cases in Buffalo, NY as having Lassa fever. August 24 Gail Brown and 50 other cases diagnosed as having Lassa in Minnesota. Sept 3 WHO released a health alert about an increase in cases of VHF in Sierra Leone. Paul Chapman sells most of the animals to Detroitarea pet stores. August 7-13 Sarah Knolls returns to Buffalo, NY after a vacation in SE Michigan. August 17 Paul Chapman diagnosed as having Lassa fever. August suspected cases were diagnosed as Lassa fever in Canada. Number of new cases in Michigan increased to 65. August 25 Decline in new cases. Most of the ill returning to normal heath. Federal and state officials consider relaxing restrictions. Oct 3 A-8

34 Appendix F Excerpt from Great Lakes Border Health Initiative Public Health Emergency Communication Guideline A-9

35 DRAFT GREAT LAKES BORDER HEALTH INITIATIVE Infectious Disease Emergency Communication Guideline Ministry of Health and Long-Term Care Ministére de la Santé et des Soins de longue durée PARTNERS Michigan Department of Community Health Minnesota Department of Health Ontario Ministry of Health and Long-Term Care New York State Department of Health Wisconsin Division of Public Health Local and tribal units bordering Ontario WISCONSIN DEPARTMENT OF HEALTH AND FAMILY SERVICES Revised: August 17, 2006

36 DECISION TREE FOR EVENTS WHICH REQUIRE PUBLIC HEALTH AGENCY DRAFT 1. Might the event have a serious public health impact across the border?* 2. Is there a significant risk of international spread? * NOTIFICATION BETWEEN ONTARIO AND NEIGHBORING STATES If #1,2 AND 3= NO, no notification necessary at this time. Continue monitoring. If #1 = NO, but #2 or #3= YES, non-immediate notification as follows If #1= YES, but NEITHER #2 nor #3= YES, non-immediate notification as follows 3. Might international travel or trade restrictions be necessary? * If #1 AND either #2 or #3= YES, IMMEDIATE notification as follows PROCEED WITH PROPER NOTIFICATION: Situational alerts may be shared across borders via Health Alert Networks. Communications which require sharing of individually identifiable data should be shared via phone or internet. A. Event involving single local health unit across the international border: Notify local health unit across the border and/or own provincial/state public health agencies.^ B. Event involving more than a single local health unit across the international border: Notify own state/provincial health agency and then cross-border state/ provincial health agency.^ (See following Appendices for Communication Protocols: page 5 for Definitions/ Examples, and page 6 for Useful Information to Provide) ^ State/provincial health units should consult the World Health Organization s International Health Regulations Annex 2 Decision Tree for the Assessment and Notification of Events that May Constitute a Public Health Emergency of International Concern to determine duty to report to their Federal Health Agency. See For routine reporting of notifiable diseases between Ontario and U.S., report to the appropriate local health unit (See Appendix 6 for listing of notifiable diseases and Appendix 7 for appropriate contact lists). * See definitions/examples Appendix 1(Flow sheet adapted from 11/04 World Health Organization s draft International Health Regulations found at: 4 GREAT LAKES BORDER HEALTH INITIATIVE INFECTIOUS DISEASE EMERGENCY COMMUNICATIONS GUIDELINE

37 DEFINITIONS/EXAMPLES FOR DECISION TREE FOR EVENTS WHICH REQUIRE PUBLIC HEALTH AGENCY NOTIFICATION 1. MIGHT THE EVENT HAVE A SERIOUS PUBLIC HEALTH IMPACT ACROSS THE BORDER? a. Event due to unknown agent with unpredictable public health impact b. Event due to known agent with the following factors: i. Unusual disease pattern (e.g. unusual season, route of transmission, severity, i.e. the number of deaths for this type of event large for the given place and time) ii. Previously eradicated agent (e.g. smallpox) iii. Known agent but new for the geographical region (e.g. West Nile Virus for North America before 2000) iv. Potential to cause epidemic even if no or few human cases are being identified. v. Indication of treatment failure (emerging resistance, vaccine failure or antidote resistance or failure) vi. Known potential to cause severe illness c. Accidental or intentional release of dangerous, banned or restricted chemical or radio active agent DRAFT 2. IS THERE A LIKELIHOOD OF CROSS-BORDER SPREAD? a. Evidence of epidemiological link to similar events in other countries b. Need to alert in regard to the potential for cross border movement of the agent, vehicle or host (recent travel, international gathering, air or water contamination) c. Cross border assistance is needed to detect, investigate, respond and control the current event, or prevent new cases. d. Inadequate human, financial, material or technical resources (laboratory, epidemiological, treatments, equipment, surveillance systems) 3. MIGHT INTERNATIONAL TRAVEL OR TRADE RESTRICTIONS BE NECESSARY? a. Similar events in the past have resulted in international restriction on trade and/or travel across the border b. The source is suspected or known to be a food product, water or any other goods that might be contaminated that has been exported/imported across the border c. The event might have occurred in association with an international gathering d. The event has caused requests for more information by cross border officials or media GREAT LAKES BORDER HEALTH INITIATIVE INFECTIOUS DISEASE EMERGENCY COMMUNICATIONS GUIDELINE 5

38 EPIDEMIOLOGIC DATA TO SHARE ACROSS STATE AND INTERNATIONAL BORDERS NOTE: PATIENT IDENTIFIABLE EPIDEMIOLOGIC DATA IS NOT TO BE SHARED VIA ELECTRONIC ALERTING SYSTEMS. DRAFT 1. Select Surveillance: Epidemiologic data necessary for identifying trends or distribution of infectious disease. This information may be accessed through public health websites. a) Examples include first West Nile Virus activity of the season. i. Activity levels or summaries which may include aggregate data ii. Sentinel infectious disease reports 2. Case/Contact Reporting*: Epidemiologic data necessary for cross-border contact investigation. a) Includes the following items below, and any other data deemed relevant by the communicable disease investigator. *If reporting contact, do not provide patient-identifiable information for the case patient. i. Laboratory test results with testing agency, location, date and specimen source ii. Name of case/contact iii. Date of Birth of case/contact iv. Address of case/contact v. Phone number of case/contact vi. Name/title of reporting individual vii. Symptoms/severity of illness viii. Date of exposure of contact ix. Mechanism/means of contact x. Type of exposure (infectious, environmental, unknown, etc.) xi. Date of onset xii. Place/Address of exposure xiii. Hospitalization/Death xiv. Recent travel history xv. Lead contact professional and contact information for that individual 6 GREAT LAKES BORDER HEALTH INITIATIVE INFECTIOUS DISEASE EMERGENCY COMMUNICATIONS GUIDELINE