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The purpose of this pandemic influenza tabletop exercise package is to provide states and local areas with tools to assist in planning and conducting tabletop exercises on the topic of pandemic influenza. Exercises serve to identify where plans may need to be refined or modified, and thus lead to strengthening preparedness. Exercises should be viewed as an integral part of planning activities.

This package includes two exercises: an overview exercise and a surge capacity exercise, as well as other resources helpful in planning and conducting these exercises. The exercises are designed for use at the state or local levels, and are designed to be general enough to be useful in any area. Users are encouraged to tailor the exercises as needed to meet their needs. The exercises and other resources included in the package are described below.

Objectives of the exercises

The objectives of these exercises are to:

Raise awareness about impact of pandemic influenza on the health care system
Increase understanding regarding the responsibilities of all participating agencies
Determine whether current plans adequately address anticipated events
Identify gaps in coordination between agencies
Promote advance planning between health departments, hospitals, and other agencies.

Brief description of the exercises

Overview exercise The overview exercise addresses planning issues that will arise during the course of an influenza pandemic over an array of areas, including surveillance, vaccination, antiviral medications, communications, and emergency response. Participants for the overview exercise will include people who will be involved in planning for and responding to a pandemic, including, but not limited to staff in the areas of public health, public information, public safety, emergency management, and health care. The emphasis of this exercise is on the public health response.

Surge capacity exercise The surge capacity exercise focuses on medical surge capacity issues; these issues are addressed in greater depth than in the overview exercise. Participants for the surge capacity exercise will be from the same groups as for the overview exercise, but more heavily skewed toward representatives of local hospitals and emergency management services. The emphasis of this exercise is on the response of the health care system. Issues related to surveillance, vaccination, and antiviral medications are not addressed in this exercise.

Exercise Structure

Tabletop exercises can be structured in a number of different ways, for example involving functional groups, mixed groups, or a single large group with representatives from all relevant agencies. There are pros and cons to each approach. The approach should be selected based on specific objectives and composition of participants (e.g., would there be enough participants from each functional area to create functional groups?).

Functional group approach: In this approach, persons who share the same responsibilities are grouped together (e.g., epidemiologists and emergency management staff are in different groups). An advantage of functional groups is that when different functional groups tackle the same question, they often make assumptions about the role of others. Identification of these assumptions during the discussion period can will lead to improved planning. In addition, participants may feel more at ease in a functional group than in a mixed group.

Mixed group approach: In this approach, persons are not grouped on the basis of shared responsibilities but rather are mixed together. An advantage to the mixed group approach is that more perspectives will be represented in the discussions within groups, providing participants with more information about the roles of other agencies. For this approach to be successful, however, participants need to have a reasonably good grasp of the role of their organization in an influenza pandemic and be familiar with their agency's response plan.

A single mixed group: In this approach, participants are not separated into groups; they interact directly with the facilitator. This approach requires having a facilitator who is knowledgeable about pandemic influenza and whose role is to pose questions to the group, calling on different agencies and generating discussion among the participants. This approach may be ideal for exercises conducted to raise awareness of pandemic influenza issues with high-level agency representatives.

An additional consideration is that some questions lend themselves best to either functional or mixed group approaches. One possible approach is to use both functional and mixed groups by structuring the day so that one part is done in functional groups (e.g., the first part as participants warm up) and the other part in mixed groups. Mixed group versus functional group questions are suggested in the surge capacity exercise questions.

It is important to set aside enough time for each group to present the issues and solutions identified, so that reality checks from others can be provided.

RESOURCES

Reference materials
Pandemic influenza slide set: This annotated slide set can be used to prepare a background presentation for tabletop participants. More slides are included than would be used in a presentation. Users should feel free to tailor the presentation to their needs (annotated slide set.ppt [PPT - 3.25MB]).

Pandemic influenza fact sheet: It may be helpful to send this brief overview of pandemic influenza to participants ahead of time [https://www.cdc.gov/flu/avian/gen-info/pandemics.htm)

Association of State and Territorial Health Officials (ASTHO) Guide to Preparedness – Evaluation [PDF - 2.61MB]Using Drills and Table Top Exercises

Planning Guidance for State and Local Health Departments (Annex 1 in the draft National Pandemic Influenza Preparedness and response Plan) (https://www.dhhs.gov/nvpo/pandemicplan/index.html)
Simulated news clips: The purpose of these simulated new clips is to increase the sense of realism for exercise participants. The 3 segments correspond to parts A, B, and C of the overview exercise. All 3 or just the third can be used in conjunction with the surge capacity exercise. The segments last about 2 minutes each [panfluMOCK_NEWS.wmv] [WMV - 3.68MB].
FluSurge: This spreadsheet tool is meant to accompany the surge capacity exercise. The user enters minimal information into a spreadsheet—specifically, population in jurisdiction and information on number of staffed hospital beds, ICU beds and ventilators. The spreadsheet then generates the number of hospitalizations and deaths expected over the course of a pandemic and calculates for each pandemic week what proportion of existing staffed beds and ventilators would be occupied by influenza cases. The number of hospitalizations and deaths are generated using the FluAid methodology [insert Web address]. Although these numbers are estimates, they provide a useful starting point in planning for surge capacity issues and set the stage for the surge capacity exercise.
- The FluSurge Spreadsheet and User's Manual https://www.dhhs.gov/nvpo/pandemics/
Evaluation: Evaluation planning activities should be an integral part of the exercise planning and design process. The content of the evaluation will be guided by specific objectives of the exercise planners. Examples of questions an evaluation may seek to answer include:
- Did the exercise meet participant needs and expectations? How can future exercises be improved? This is the most typical type of evaluation conducted.
- Did the exercise motivate participants to develop collaborations and partnerships with other agencies? This question can be answered in part by asking participants to describe current working relationships with other agencies before the exercise begins, and asking them with whom they plan to develop relationships at the end of the exercise.
- Is the level of participant preparedness increasing over time? In situations where agencies will participate in exercises repeatedly, relevant data may be collected over time to track trends in indicators of organizational and community preparedness.

OVERVIEW EXERCISE

Part A
In late September of ___(insert year), an outbreak of unusually severe respiratory illness is identified in a small village in southern China. At least 25 cases have occurred, affecting all age groups; 20 patients required hospitalization, 5 of whom have died to date. Surveillance in surrounding areas is increased, and new cases begin to be identified throughout the province. Viral cultures collected from several of the initial patients are positive for type A influenza virus. The isolates are sent to the World Health Organization (WHO) Collaborating Center for Surveillance Epidemiology and Control of Influenza at the Centers for Disease Control and Prevention (CDC) in Atlanta, for further characterization. CDC determines that the isolates are type A H7N3, a subtype never before isolated from humans.

This information is immediately transmitted back to the Ministry of Health in China and throughout the WHO network. CDC, in collaboration with WHO, dispatches a team of epidemiologists and laboratory personnel to further evaluate the outbreak and disseminates a Health Alert Network (HAN) advisory notifying clinicians and U.S. state health departments to be on the alert for patients with severe respiratory illness and a history of travel to the region of Asia where the human cases occurred. Isolates of the H7N3 virus are sent to the WHO Collaborating Centers and to the U.S. Food and Drug Administration (FDA), so that work can begin to produce a reference strain for vaccine production. Influenza vaccine manufacturers are placed on alert. The outbreak caused by the novel influenza virus begins to make headlines in every major newspaper and becomes the lead story on major news networks. Key U.S. government officials are briefed on a daily basis as surveillance is intensified throughout Southeast Asia and the Pacific Rim.

By mid-November, human cases of H7N3 have been reported in Hong Kong, Singapore, South Korea, and Japan. Although cases are reported in all age groups, young adults appear to be the most severely affected, and case-fatality rates approach 5%. Public unease grows because vaccine is not yet available and supplies of antiviral drugs are severely limited.

In early December, human cases are identified in the United States. CDC reports that the H7N3 virus is isolated from ill airline passengers arriving from Hong Kong and Tokyo in Los Angeles, Honolulu, Chicago, and New York. State and local agencies are asked to intensify influenza surveillance. Vaccine manufacturers are asking when the vaccine seed viruses will be available. Anticipating the arrival of the new flu strain in ________________ (insert your jurisdiction) within the next few weeks, what steps must be taken to prepare?

Questions:

Who is leading the public health response and what are the roles and responsibilities of the persons who report to this individual?
What are the key issues the health department needs to address at this point?
Who are the key partners with whom these issues need to be addressed?
What specific assistance will (county/city) need from external agencies/organizations?
What steps are being taken to prepare the provider community and the general public for the events of the next 2-3 months?
What kinds of messages need to be crafted for the public before the outbreak occurs and in response to predictable issues once the outbreak occurs?
How are you working with local media so they will help your efforts?
How are non-English speaking populations being addressed?
What plans do you have in place to step up surveillance activities? Where will additional staff needed for extra workload come from?
On what medical care-related areas does public health need to collaborate with the hospitals, emergency rooms and outpatient providers?
What plans been developed to vaccinate priority groups after first shipments of vaccine arrive?
Are plans in place for mass vaccination? If so, in what locations and who will staff them?

Part B
It is now late December. Local outbreaks have been reported in major cities throughout the United States. In _______ (insert jurisdiction), the impact has begun to be felt in earnest as evidenced by a noticeable increase in the number of persons presenting to emergency rooms with symptoms consistent with influenza. Phones at physician offices and the health department begin to ring constantly. More people are seeking medical care than actually need it, due to fear about the new strain of virus.

Rates of absenteeism in schools and businesses begin to rise. Similarly, personnel in key positions (health care, law enforcement, and other emergency personnel) are absent due to illness or caring for ill family members.

Nationwide, accounts of illness are reported by the media. Citizens begin to clamor for the vaccine, but it will still be another month or two at the earliest until the first vaccine is available. After it starts to become available, the vaccine will need to be given to certain high priority groups because there won't be enough at once for the entire population. Angry phone calls to elected officials reflect frustration and lack of understanding about why the limited vaccine is being targeted only for certain personnel and will not be distributed to the general public.

Some local pharmacies have run out of antiviral medications and are unsure whether they can expect to receive more. Although the health department has issued guidelines to physicians on antiviral medication use and has emphasized the importance of prioritizing persons with underlying illnesses who have recent onset of influenza symptoms, anecdotal information suggests that physicians have been prescribing antiviral medications more broadly. __ (city, county, state) has been allotted and has received a small supply of antivirals from ___ _(state, CDC), and public concern over the way in which the antiviral medications will be utilized is increasing.

Questions:

How do you plan to address anticipated staff shortages in the health department; what essential functions must remain in place? Who decides how limited staff and other resources are allocated?
What essential services must be maintained in the county? How will resources be allocated and accounted for in order to maintain these services? Who decides these issues?
What role is public health playing with respect to hospitals and the prospect of facilities being overwhelmed? Are you tracking availability of beds?
How are laboratory services being prioritized to deal with the high demand as well as staff shortages?
You are receiving daily inquiries about the number dying of influenza. How are you responding? How severe is the pandemic in your area and how do you know this?
In anticipation of soon receiving vaccine that will be targeted for health-care workers and first responders, how are you addressing public concerns about lack of vaccine?
Health care workers and first responders express concern about exposure. What advice can be given?
What are your plans to manage the very small supply of antiviral medications received from ___ (state, CDC)?
How will you prioritize who gets antiviral medications, and how will you distribute these medications?
What are the primary responsibilities of 911 dispatch, sheriff, police, and fire departments? What resources will they need?
At what point will you decide whether schools will be closed and whether public gatherings and events will be cancelled? How will you balance school closures with the impact on the workforce when parents stay home with children? Who will be involved in making these decisions?

Part C
It is now mid February. ____________ (insert jurisdiction) is overwhelmed by the number of influenza cases. Rough surveillance estimates indicate that 30% of the population is ill with H7N3 influenza.

Local hospitals and outpatient clinics are extremely short-staffed; an estimated 30% to 40% of physicians, nurses and other health-care workers are absent due to illness, caring for family members, or simply because of fear for their safety. Intensive care units are overwhelmed, and soon there is a shortage of mechanical ventilators for treatment of patients with severe respiratory syndromes or postoperative needs. Family members are distraught and outraged when loved ones die within a matter of days. Funeral homes are overwhelmed by the numbers of dead (approximately 325 in the past 3 weeks) and are unable to keep up with the need for services.

The first supplies of vaccine will arrive next week and are targeted to health-care workers and first responders.

Law enforcement, emergency medical personnel, health care, and local utility companies (power and water) also have personnel shortages, resulting in some cutbacks in routine services. Grocery stores are suffering shortages of food supplies due to the nationwide impact resulting from ill truckers who usually deliver those supplies.

Many area residents (particularly those with chronic, unstable medical conditions) are afraid to venture out for fear of becoming seriously ill with influenza. Hundreds are staying home, and their essential supplies—such as food—are becoming depleted.

Questions:

Hospitals are full, and there are severe staff shortages. The least ill patients are being sent home. Have any plans been made for provision of home health care?
What special issues need to be considered related to various populations such as persons who are geographically isolated, non-English speakers, hearing impaired persons, the elderly, and others with already limited access to healthcare?
How will the deceased be safely and respectfully handled, and how will religious beliefs be addressed?
National recommendations have been issued stating that health-care workers and first responders are the highest priority groups for vaccination when the vaccine first becomes available. As you make plans to begin vaccinating, how are you responding to the angry public that wants vaccine, and in particular to panicked parents?
Because you will not be able to vaccinate every health-care worker and first responder in your jurisdiction, how are you determining which health-care workers are eligible in this first round of vaccination?
Health-care workers are demanding that their family members also receive vaccine. How are you responding to this?
How do you plan to safeguard and monitor your vaccine?
What mental health needs of citizens, health workers, emergency responders, and others must be considered and addressed? How will this be accomplished?

Part D
It is now late March, and the number of ill persons has been on the decline for 3 weeks. Hospital staff are exhausted. All those available to assist in providing health care have been pulled in.

Vaccine is finally becoming available on a larger scale for vaccination of more people.

Questions:

The health care community, both public and private, has been stretched thin responding to the clinical are needs. Who will staff the vaccination clinics?
What can be done to alleviate the stress for those who have already been enlisted with other efforts during the past 8 weeks?
Turnout for vaccination is less than expected. What is your communication plan to increase interest in vaccination?

SURGE CAPACITY EXERCISE

Note: This exercise is not set in a scenario-driven format like the overview exercise, although a scenario-driven version may become available at a later date. This version is meant to serve as a springboard for discussion of issues. The scenario from the overview exercise can be read to set the stage for the surge capacity exercise. In addition, exercise planners should use FluSurge to estimate the impact of the pandemic on their health care system and present this information to the participants (see https://www.dhhs.gov/nvpo/pandemics/).

Questions for functional groups

Public Health
Over the course of the current pandemic, up to 35% of the local population may become ill. Most people will have a typical course of illness consisting of 3 days of severe febrile illness, followed by a few days of milder symptoms and 1, 2, or more weeks of convalescence. These illnesses will result in a marked surge in demand for outpatient medical services, as well as antiviral medications and over-the-counter remedies. Health education may reduce the impact on outpatient care providers.

Does your community have a plan to educate local residents on subjects such as how to care for milder cases at home, symptoms pointing to the need for professional medical care, who will be at higher risk of serious illness, and where to go for medical care if residents do not have a regular source of medical care?
When should the educational program begin?
Who would be the best spokesperson(s) for the educational program?
Who has (should have) primary responsibility for developing local health communication programs?

Hospitals
Hospital capacity is being rapidly (if not already) exceeded. What approaches to expansion of capacity will be used in your community?

Open alternate or expand current facilities? Will the newly available beds in these facilities meet the need?
Will there be adequate staffing, equipment and services to make the newly available beds usable for patient care?
Will admission criteria be modified?
Will discharge criteria be modified? Cancel elective procedures?
Other measures?
How will changes in standards be addressed from a legal point of view?

Experience indicates that respiratory failure associated with pneumonia is the major cause of death in influenza. Patients having a co-morbid illness such as diabetes, chronic obstructive pulmonary disease (COPD), or heart disease are at high risk of developing pneumonia. Influenza patients at risk of death due to respiratory failure will require a minimum of 10 days of intensive care, including ventilator support. In most hospitals the need for ventilators will exceed what is available.

What recommendations would you make for establishing priority of access to ICU care and mechanical ventilation? Would such priorities have any meaningful impact on who does or does not receive ICU care?
What problems would be encountered in expanding availability of ICU care and mechanical ventilation?
If you knew with certainty that your community was going to suffer an influenza pandemic with the projected impact, what would be your preparedness recommendations to meet the shortfall in ICU beds? How do these recommendations differ from current preparedness plans?
Will available radiology and laboratory (microbiology and clinical) services be adequate to meet the demand? Will providing service for expanded or ancillary facilities create problems?

Staff shortages, particularly in nursing, have been a problem in previous influenza epidemics.

Are good data available on the size of the potential pool of various skills that may be available to meet the surge in need?
Will there be authority to waive credentialing requirements for persons with the necessary skills but who are not currently licensed?
Has your jurisdiction looked into legal issues that may affect your ability to use volunteers and other non-credentialed staff?
Is changing nurse/patient ratios a reasonable short-term option?
Using volunteers and/or patient family members?
Other approaches?

EMS
Requests for patient transport have surged, and this increased demand will be sustained for weeks. In many communities, the system is staffed on a historic call volume basis with about a 20% surge capacity at a cost of a moderate increase in response time. This surge capacity is difficult to maintain on a sustained basis.

What is the average daily number of requests for patient transport services in your community? What is the surge capacity? Could the system handle a surge of 30% or more requests on a daily basis during the peak period? How long can this increased level of response be sustained?
Is there a priority system in providing patient transport? Who decides the priority? What criteria are used in making the decision?
Is there a mutual aid agreement if requests for patient transport cannot be met? In your opinion, would this agreement be workable during an influenza pandemic?
What alternative sources could be used for patient transport?
Are there areas that are chronically underserved for which special plans need to be made?

Public Safety
Disruptions in public order at health care facilities and clinics may occur as a result of behaviors related to anxieties of persons seeking care for their loved ones.

Have plans been made to enhance security in times of emergency?
How many points of entry are there? Do you have security staff to cover all areas?
Will traffic control be a potential problem?
Will parking availability be adequate?
Will security be adequate to protect supplies of critical shortage materials and equipment?
If large numbers of law enforcement personnel are affected, who will provide the necessary services?

Mortuary Services
Pandemic influenza will create an unusual demand for mortuary services. Bodies will need to be processed from hospital and out-of-hospital sources.

Who is responsible for announcing an expedited process of body handling?
How will medical autopsy process be modified by the appropriate medical examiner?
Are resources available to manage bodies that cannot be processed quickly through the hospital, medical examiner, funeral home and burial process?
What authority would suggest an expedited process for funerals and burials?
What authority could process bodies if a regional crematory was not properly disposing of bodies?
Who is responsible for deaths in the home? Are autopsies required, and if so, can a waiver be obtained?

Administrators
Pandemic influenza will create a financial burden on the community and the health care system. General business conditions will deteriorate. The health care system will endure higher costs and reduced revenues. What planning can be done to mitigate short- and long-term financial effects?

Is the system prepared to finance unusual expenses for workup and care of influenza victims?
Is the health system capable of paying for higher staff costs, overtime, and loss of regular staff?
What resources can be activated to compensate for decreased revenues as the day-to-day patient volume is eliminated?
Given that health care systems likely cannot request pre-payment, how will hospitals manage to cover costs until reimbursement occurs?
Is the local system capable of guaranteeing payment to other service and equipment vendors needed to manage the outbreak, even in crisis conditions?

Questions for mixed groups

The national impact of the pandemic has limited availability of pharmaceuticals, medical supplies, and equipment.

What would be the best approach to assure equitable distribution of needed materials among health-care providers?
Should the needs of health-care providers be tracked at some central point, and should ordering of new supplies and equipment be coordinated? If this is desirable, who should have the responsibility?

Key Groups: Public Health, Hospitals, EMA
The mental health and social service needs created by the pandemic will be great. Coping with deaths of loved ones, arranging for care of seriously ill persons, and other demands will cause more mental anxiety than many can handle.

What would be priority needs for mental health and social services? How would you rate their priority in relation to patient care needs?
Does your community have a plan to provide for a surge in mental health and social services needs? In your opinion, is the plan adequate to meet the potential needs posed by an influenza pandemic?
What factors might limit provision of adequate services?
Who should participate in preparations to address mental health and social service needs?
Have the special needs of those providing health care and other essential services been considered?
Who will or should coordinate provision of these services?
What is the role of voluntary and religious organizations? Is someone responsible for coordinating their efforts?

Key Groups: Public Health, Red Cross, Hospitals, Mental Health, EMS
As in any emergency, communications will be an essential component of the response to an influenza pandemic.

What process is in place to improve the consistency and timeliness of health care information released to the health-care providers and the general public?
What agency or organization will be empowered to release appropriate information?
Is that same agency the designated central communications hub?
oes your community have secure communications for transmission of sensitive information between hospitals, the emergency management agency, emergency medical services, and the health department?
Is there redundancy in the communication system?
Should a central communications hub be established?

Key Groups: Public Health, EMA, Hospitals, EMS
Pandemic influenza will be widespread; many geographic areas will be affected simultaneously. Thus, unlike a focal disaster, every community must be prepared to meet many of the response challenges with limited help from surrounding communities or from state and federal resources. Some potential problem areas have been identified, as follows: 1) shortfalls of ICU beds, ventilators, and other critical care items; 2) shortages of antiviral agents and antibiotics for treatment of secondary bacterial infections; 3) needs for ancillary or “non-traditional” treatment centers”; and 4) high demand for social and counseling services.

What are channels and procedures are available for requesting emergency help from state and federal resources?
Who is empowered to request state and federal resources, and to specify what resources are needed?
How would requests for assistance be managed in a metropolitan area that extends over multiple counties in more than one state?

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Pandemic Influenza Tabletop Exercise Package

Exercise Structure

RESOURCES

OVERVIEW EXERCISE

SURGE CAPACITY EXERCISE

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