2013 British Columbia/Washington State Cross Border Infectious Disease/Pandemic Tabletop Exercise

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1 2013 British Columbia/Washington State Cross Border Infectious Disease/Pandemic Tabletop Exercise After-Action Report Dec

2 EXERCISE OVERVIEW Exercise Name 2013 British Columbia/Washington State Cross Border Infectious Disease/Pandemic Tabletop Exercise Exercise Date November 5, 2013 Scope Mission Area(s) Capabilities The BC Ministry of Health Emergency Management Unit (EMU) and Washington State Department of Health (DOH) held an Infectious Disease/ Pandemic tabletop exercise to assess current cross border information sharing strategies. The purpose of the exercise was to validate and/or identify any gaps in cross border pandemic coordination. The exercise provided an opportunity to build on existing communications structures and to further develop communication plans between Washington and BC. This was accomplished by focusing on Cross Border collaboration during a pandemic event. This exercise was a cooperative forum focusing on reviewing and building cross border communications tools, verifying jurisdictional differences in pandemic response practices, and identifying key messages and stakeholder actions. Prevention, Mitigation, & Response Community Preparedness, Emergency Operations Coordination, Public Information and Warning, Information Sharing, Medical Surge, and Surveillance and Epidemiology Objectives Assess current cross border information sharing strategies between Washington State and BC Assess processes for coordinating cross border public messaging Identify how to communicate cross border differences in public health protective measures Identify gaps in cross border public health coordination during emergencies Threat or Hazard Scenario Communicable Disease The exercise used two different scenarios. The first focused on a possible Measles outbreak that started in the Seattle area, and then through contact at a youth Soccer tournament, spread into British Columbia. The second scenario involved confirmed cases of MERS-CoV developing into a pandemic (affecting both jurisdictions). 2

3 Sponsors Participating Organizations British Columbia Ministry of Health, Emergency Management Unit Washington State Department of Health, Office of Emergency Preparedness and Response. 25 participants in total, representing Federal, Provincial, and First Nations Health in BC, and State Health in Washington. Jocelyn Hawse, Emergency Manager Emergency Management Unit - Ministry of Health ; Jocelyn.Hawse@gov.bc.ca Blanshard St. Victoria BC V8W 3C8 Point of Contact Daniel Banks, Plans, Operations, and Exercise Manager, Office of Emergency Preparedness and Response, Washington State Department of Health dan.banks@doh.wa.gov PO Box 4796o Olympia, WA

4 ANALYSIS OF CAPABILITIES Aligning exercise objectives and capabilities provides a consistent taxonomy for evaluation that transcends individual exercises to support preparedness reporting and trend analysis. Table 1 includes the exercise objectives, aligned capabilities, and performance ratings for each capability as observed during the exercise and determined by the evaluation team. Objective Assess current cross border information sharing strategies between Washington State and BC Assess processes for coordinating cross border public messaging Identify how to communicate cross border differences in public health protective measures Identify gaps in cross border public health coordination during emergencies Capability Community Preparedness, Emergency Operations Coordination, Public Information and Warning, Information Sharing, and Surveillance and Epidemiology Same as above Same as above Same as above Performed without Challenges (P) Performed with Some Challenges (S) X X X X Performed with Major Challenges (M) Unable to be Performed (U) Ratings Definitions: Performed without Challenges (P): The targets and critical tasks associated with the capability were completed in a manner that achieved the objective(s) and did not negatively impact the performance of other activities. Performance of this activity did not contribute to additional health and/or safety risks for the public or for emergency workers, and it was conducted in accordance with applicable plans, policies, procedures, regulations, and laws. Performed with Some Challenges (S): The targets and critical tasks associated with the capability were completed in a manner that achieved the objective(s) and did not negatively impact the performance of other activities. Performance of this activity did not contribute to additional health and/or safety risks for the public or for emergency workers, and it was conducted in accordance with applicable plans, policies, procedures, regulations, and laws. However, opportunities to enhance effectiveness and/or efficiency were identified. Performed with Major Challenges (M): The targets and critical tasks associated with the capability were completed in a manner that achieved the objective(s), but some or all of the following were observed: demonstrated performance had a negative impact on the performance of other activities; contributed to additional health and/or safety risks for the public or for emergency workers; and/or was not conducted in accordance with applicable plans, policies, procedures, regulations, and laws. Unable to be Performed (U): The targets and critical tasks associated with the capability were not performed in a manner that achieved the objective(s).

5 SUMMARY OF OBSERVATIONS Activity: A measles outbreak is affecting areas of Seattle, Vashon Island, Greater Vancouver, and Victoria. There are a large number of people that are potentially infected and have been travelling across the border. Observations: When an infectious disease outbreak occurs Washington State DOH Epidemiology and BC Centre for Disease Control (BCCDC) contact each other directly. Washington DOH and BCCDC have an online notification system for communicating outbreaks to health professionals as well as a public health notification system that spans both countries. Once an outbreak is confirmed, both Washington DOH and BCCDC would notify their federal counterparts. BCCDC on behalf of the BC Public Health Officer (PHO) will communicate the outbreak to appropriate parties within the province, including the First Nations Health Authority (FNHA). In BC, the health authorities would expect province wide messaging to be initiated from BCCDC and MOH to ensure standardized message and approach. Each HA would speak to HA specific issues eg. # of cases In Washington, the county will notify the State DOH who would then communicate with bordering states and provinces. The development of communications tools between Provincial and State Health in British Columbia and Washington State remains very strong. Communications processes are currently well developed but not documented. The health sector has used the Pacific Northwest Emergency Management Arrangement (PNEMA), to overcome any legal issue to the exchange of information back and forth across the border. There is not a large role for federal entities in this scenario, they are likely to be notified and may be asking for information if there is a strong media interest. Physicians in BC s First Nations Health Authority (FNHA) do not yet have Order in Council appointments, which would give them legal authority to receive lab results and issue orders. First Nations healthcare delivery in British Columbia is undergoing significant change, allowing for new opportunities in cross border relationship building. In BC, the FNHA is a tripartite entity, whereas in Washington State healthcare delivery to tribal members is provided by several different entities. Emergency Management would likely be linked in once there is a confirmed outbreak, but not if there is a handful of cases. When beginning a response to a communicable disease, one of the issues that comes up is how and when to incorporate emergency management partners.

6 Emergency Management functions as a valuable resource to agencies responding to a public health incident, but the timing of contact and flow of information can be challenging for both sides. Ensuring that healthcare workers are vaccinated is a priority in this case. Healthcare worker immunity levels greatly impact the ability to deliver healthcare during an outbreak. Although many institutions require healthcare workers to provide proof of immunity for a virus such as measles, enforcement and verification is difficult. Testing during an outbreak adds to the burden of investigation and can overwhelm labs and complicate results, the need for surge supplies at public health labs is recognized. Immunization of school children remains a significant issue in Washington State. This will have implications for bordering jurisdictions during outbreaks. Activity: A Middle East Respiratory coronavirus (MERS-CoV) case has been confirmed in Vancouver BC. Family members are showing signs of illness and have travelled through the Seattle area. Four months later the virus has evolved and spread and the WHO has declared a pandemic. Observations: BCCDC, Washington DOH Epidemiology and communications from both jurisdictions receive a notification each time a MERS-CoV test is ordered. Notification happens across the border once a case has been confirmed. There are no existing protocols for coordinating cross border messaging, but informal notification strategies between Washington and BC. Contact lists for cross border partners are updated through the Pacific Northwest Border Health Alliance (PNWBHA). Information flows differently through the healthcare systems in BC and Washington, and these different processes can potentially inhibit cross border communication. Consistent terminology in public messaging on both sides of the border is important. BC and Washington currently contact each other ahead of time to inform of what messages will be delivered by the media. Public messaging will occur differently on either side of the border. Need to communicate to the public the reason for differences in messaging and practices on either side of the border. BC and Washington both provide up to date guidelines for medical staff on a physician facing website. If lab testing abilities are overwhelmed, would reach out to cross border partners. There are limitations in the type of content and method of delivery when disseminating epidemiological information across the border.

7 In BC there is less federal involvement because health is a provincial responsibility, whereas Washington may have access to resources from the Centre for Disease Control (CDC). In a pandemic situation it is likely that outside assistance will not be available because of widespread demand for the same type of resources. Pandemic planning should focus on using the resources that one has available locally and not outside sources for surge support. Due to the different governmental and healthcare structures on either side of the border, the federal government s role in communicable disease response is different. In the US much of the healthcare surge capacity is at the federal level, while in Canada, much of this is at the provincial level In Washington State much of the legal authority belongs to the local health officer while in BC lies with Regional and Provincial authorities. The difference can lead to confusion during an incident and unnecessarily delay the ability to respond properly. If transportation companies are involved, would need to coordinate with the company to ensure consistent messaging to those potentially infected during travel. Contact tracing in the case of a contagious individual on an airplane can be very difficult and require the commitment of scarce resources. Need to manage expectations for tracking an infected traveler and the issues that surround communicable disease and travel on aircraft. Conference calls in particular tend to multiply during a response as each group would like to discuss the issues. Valuable to set up conference call coordination before this type of incident occurs. The laws around isolation and quarantine are very different across the international and state/provincial borders. Having an understanding of how they work in neighboring jurisdictions will better prepare those dealing with the incident to understand the implications. References: Pacific Northwest Emergency Management Arrangement (PNEMA) WA-BC MOU with Respect to a Collaborative Approach to the use of Available Public Health and Health Services Resources to Prepare for, Respond to and Recover from Public Health Emergencies WA-BC MOU to Provide Mutual Aid through Sharing Public Health Laboratory Services PNWBHA Guidelines available at -Public Health Information Sharing -Public Health Laboratory Capacity -EMS Cross Border Movement

8 -Mutual Assistance Implementation -Professional Development and Capacity Building Subject Area Lesson Learned # Cross Border Information Sharing Strategies There is a need to set up conference call coordination before this type of incident occurs. There is a need to capture our current processes internally so each jurisdiction understands their cross border role and notification procedures. 1 2 Cross Border Public Messaging It is necessary to continue to build strong communications relationships as a means of avoiding confusion and delivering consistent public messaging. An opportunity is needed to go into a more detailed assessment of coordinating cross border public messaging. 3 4 Cross Border Public Health Measures and Coordination There is a need to continue to educate those on both sides of the border on the differences between the two health systems through future exercises and working groups. Identifying cross border gaps in public health coordination is still in progress, there is a need to further explore these gaps. 5 6 First Nations/Tribal Coordination FNHA and Tribal healthcare representatives need to be included in future discussions to expand Emergency Management and cross border knowledge in these areas and to continue to build strong relationships. 7

9 Parking Lot Issues There are several open issues (parking lot) that need to be addressed at a future event (appendix A). 8 Recommendations: 1) A basic scheduling guideline for conference calls will be incorporated into process development before and after an incident. 2) The EMU will work with MoH Communications staff to develop a communications algorithm for cross border notification. This does not need to be a concrete plan, but rather a documented communications protocol for consistent transfer of information as staff members turn over. 3) Communications staff will continue to be involved in future cross border events to build strong relationships. An update on the communications protocol will be presented at the Cross Border Workshop in ) The lessons learned and recommendations from this tabletop will be presented at the Cross Border Workshop in In addition, an annual event will be scheduled to fill the gap between each Cross Border Workshop. This purpose of this event will be to: a) assess cross border public messaging in further detail b) further educate cross border partners on the differences of BC and Washington State health systems and practices c) identify additional gaps in cross border coordination d) provide opportunity to include federal partners in cross border discussions e) develop and enhance understanding of First Nations and Tribal processes f) build relationships between communications staff in Washington and BC 5) Parking lot issues will be organized into objectives for the next exercise event and suggested as agenda items during the Cross Border Workshop 2014

10 APPENDIX A: OPEN ISSUES (PARKING LOT) 1) There are challenges around public health management and emergency management links during outbreaks, how can this be improved? 2) Necessary to ensure that those that do not deal with epidemiological information day to day understand the limitations on dissemination of this information. Cross function tabletop exercise could be one method of further this goal. 3) Washington has connections across the borders both internationally and with Oregon for laboratory surge capacity. Although the agreements are in place, it never has been tested with a real specimen and how to get it through customs. A working group could be set up for developing protocols for cross border specimen transfers that includes Canadian and US Border Agencies. 4) Review pandemic planning materials to ensure that they properly address surge without available outside resources. 5) The medical community would benefit from further training on the impacts of potentially communicable passengers on airlines and contact tracing. The training should also include coverage of what the real threat to other airline passengers is from potentially communicable fellow travelers. 6) A working group could be developed on Isolation and Quarantine issues. This group should have representation from the legal, public communications, and medical functional areas. This is necessary in order to properly communicate the implication of isolation and quarantine implementation to the public and how different jurisdiction plan to implement. 7) Some non-health federal entities are uncomfortable with the way that British Columbia and Washington have used PNEMA and do not fully understand the need for quick unhindered communications during a response. Washington State s interpretation of PNEMA gives the state the ability to work directly with British Columbia in matters of emergency preparedness and response. Is this interpreted the same way by our Federal Partners? PNWBHA can delegate this to its legal working group and to make sure that the appropriate federal entities are involved in the discussion such as the Canadian Foreign Ministry, and the US Department of State.

11 APPENDIX B: EXERCISE PARTICIPANTS British Columbia Federal Public Health Agency of Canada Participating Organizations Provincial BC Ministry of Health BC Centre for Disease Control BC Provincial Health Services Authority BC First Nations Health Authority Emergency Management British Columbia (Observer) Washington State Washington State Department of Health

12 Scenario 1 APPENDIX C: EXERCISE SCENARIOS A Pacific Northwest youth soccer tournament is being held in the Seattle area on November 16 th and 17 th, Teams are being housed in hotels and homes of local families. 200 Participants are registered, boys and girls between the ages of 11 and 17, including 60 from Victoria and Greater Vancouver. Inject 1: November 20, 2013 One 12-year old Vashon Island participant went to school on the Monday after the tournament with cold symptoms, but was sent home in the afternoon with a fever. She had returned the week before from a family trip to the Netherlands. Yesterday, she woke up with a rash on her face, was taken to a hospital emergency department, admitted, and is now diagnosed with measles. Inject 2: December 9, 2013 Two youths from Canada who had been at the soccer tournament have now been diagnosed with measles, one in Greater Vancouver and the other from the Songhees Nation in Victoria. The 6 month old sibling of the child in Vancouver has been admitted to hospital with fever and white spots in his mouth and throat. Scenario 2 The Middle East respiratory syndrome coronavirus (MERS-CoV) was first detected as a novel virus in humans in April As of October 29, 2013, WHO had been informed of a total of 144 laboratory-confirmed cases of infection with MERS-CoV, including 62 deaths. Inject 1: July 7, 2014 There have been a handful of travel-related confirmed cases of MERS-CoV in central Canada and the US but none yet in the Pacific Rim. The BC Ministry of Health is aware of its first probable case of MERS-CoV in a person from Vancouver who recently returned from a trip to the Middle East. Inject 2: July 9, 2014 There is now laboratory confirmation of the MERS-CoV case in Vancouver BC. Two family members have a febrile acute respiratory illness. Inject 3: July 10, 2014 The family has informed health authorities that they landed in Seattle on their trip back from the Middle East, and then took the train north to Vancouver BC. Inject 4: November 5, 2014 MERS-CoV has evolved into a much more contagious virus with a reproductive rate of 2-3 and an estimated fatality rate of up to 15%. To date, over 30,000 cases have been reported to WHO by 70 countries. Today, WHO declares MERS-CoV a pandemic.

13 APPENDIX D: TABLE OF ACRONYMS AAR BCCDC CDC DOH EMBC EMU FNHA HHS MERS-CoV MoH PHAC PNEMA PHO PNWBHA After Action Report British Columbia Centre for Disease Control Center for Disease Control (USA) Department of Health (Washington) Emergency Management British Columbia Emergency Management Unit First Nations Health Authority Health and Human Services (Federal USA) Middle East Respiratory Coronavirus Ministry of Health Public Health Agency of Canada (Federal Canada) Pacific Northwest Emergency Management Arrangement Provincial Health Officer Pacific Northwest Border Health Alliance

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