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This electronic representation of RAND intellectual property is provided for non- commercial use only. Permission is required from RAND to reproduce, or reuse in another form, any of our research documents for commercial use. This product is part of the RAND Corporation technical report series. Reports may include research findings on a specific topic that is limited in scope; present discus- sions of the methodology employed in research; provide literature reviews, survey instruments, modeling exercises, guidelines for practitioners and research profes- sionals, and supporting documentation; or deliver preliminary findings. All RAND reports undergo rigorous peer review to ensure that they meet high standards for re- search quality and objectivity. Bioterrorism Preparedness Training and Assessment Exercises for Local Public Health Agencies David J. Dausey, Nicole Lurie, Alexis Diamond, Barbara Meade, Roger Molander, Karen Ricci, Michael Stoto, Jeffrey Wasserman Prepared for the Department of Health and Human Services The research described in the report was prepared for the Department of Health and Human Services by RAND Health, a unit of the RAND Corporation. The RAND Corporation is a nonprofit research organization providing objective analysis and effective solutions that address the challenges facing the public and private sectors around the world. RAND’s publications do not necessarily reflect the opinions of its research clients and sponsors. R ® is a registered trademark. A profile of RAND Health, abstracts of its publications, and ordering information can be found on the RAND Health home page at www.rand.org/health. © Copyright 2005 RAND Corporation All rights reserved. No part of this book may be reproduced in any form by any electronic or mechanical means (including photocopying, recording, or information storage and retrieval) without permission in writing from RAND. Published 2005 by the RAND Corporation 1776 Main Street, P.O. Box 2138, Santa Monica, CA 90407-2138 1200 South Hayes Street, Arlington, VA 22202-5050 201 North Craig Street, Suite 202, Pittsburgh, PA 15213-1516 RAND URL: http://www.rand.org/ To order RAND documents or to obtain additional information, contact Distribution Services: Telephone: (310) 451-7002; Fax: (310) 451-6915; Email: [email protected] Preface One of the challenges of public health since September 11, 2001, and the subsequent anthrax attacks has been to improve bioterrorism preparedness in state and local public health agencies. In order to accomplish this task, however, we must first develop tools and indicators to measure bioterrorism preparedness reliably so that gaps in bioterrorism preparedness can be identified and improvements can be measured over time. This operations manual presents a series of tabletop exercises that focus on bioterrorism preparedness for local public health agencies to use to measure and assess their levels of bioterrorism preparedness. The exercises focus on the public health response to a bioterrorism emergency in the first few hours to days of an emergency, when local public health agencies are the primary actors involved in detecting and initially responding to the emergency. We refined these exercises by beta testing them at 13 metropolitan area local public health agencies over the course of 10 months. The contents of this manual will be of interest to public health professionals at the state and local levels who are involved in bioterrorism response in their agencies. This work was supported by the U.S. Department of Health and Human Services under contract No. 282-00-0005, for which Dr. William Raub, Principal Deputy Assistant Secretary for Public Health Emergency Preparedness, serves as project officer. The research was conducted in RAND Health’s Center for Domestic and International Health Security. RAND Health is a division of the RAND Corporation. A profile of RAND Health, abstracts of its publications, and ordering information can be found at www.rand.org/health. iii Table of Contents Preface........................................................................................................................ iii Table of Figures......................................................................................................... vi Summary.................................................................................................................... vii Acknowledgments...................................................................................................... ix Acronyms................................................................................................................... x Chapter One. Introduction........................................................................................ 1 Objectives and Structure of Manual................................................................. 1 General Exercise Format................................................................................... 2 Issue Areas Covered......................................................................................... 3 Exercise Types.................................................................................................. 4 Agents Used in Exercises.................................................................................. 4 Chapter Two. Planning an Exercise.......................................................................... 5 Exercise Frequency........................................................................................... 5 Staffing and Materials....................................................................................... 5 Choosing and Customizing an Exercise........................................................... 6 Choosing and Recruiting Participants............................................................... 8 Choosing a Venue and Setting up a Room for an Exercise.............................. 9 Chapter Three. Learning to Facilitate an Exercise.................................................... 10 Training and Preparation to Facilitate an Exercise .......................................... 10 Using Checklists and Probes............................................................................. 10 Achieving a Balanced Facilitation Style........................................................... 12 Chapter Four. Conducting an Exercise .................................................................... 13 Broad Framework for Conducting an Exercise ............................................... 13 Initial Situation Report...................................................................................... 14 Case Reports..................................................................................................... 14 Situation Updates.............................................................................................. 15 Hot Wash.......................................................................................................... 16 Chapter Five. Using Exercises for Continuous Quality Improvement..................... 17 Overview........................................................................................................... 17 Plan-Do-Study-Act........................................................................................... 17 Appendix A. Short Exercises.................................................................................... 19 A1. Anthrax Short Exercise Template............................................................. 20 A2. Botulism Short Exercise Template........................................................... 25 A3. Plague Short Exercise Template............................................................... 30 A4. Smallpox Short Exercise Template........................................................... 35 A5. Checklists for Short Exercises.................................................................. 40 Appendix B. Medium Exercises............................................................................... 43 B1. Anthrax Medium Exercise Template........................................................ 44 B2. Botulism Medium Exercise Template....................................................... 53 B3. Plague Medium Exercise Template........................................................... 62 B4. Smallpox Medium Exercise Template...................................................... 71 B5. Checklists for Medium Exercises.............................................................. 80 Appendix C. Long Exercise...................................................................................... 86 C1. Long Exercise............................................................................................ 87 iv C2. Step 1......................................................................................................... 90 C3. Step 2......................................................................................................... 95 C4. Step 3......................................................................................................... 97 C5. Checklists for Long Exercise....................................................................100 Appendix D. Create-Your-Own Exercise.................................................................106 Appendix E. Frequently Asked Questions................................................................110 References..................................................................................................................112 v Table of Figures 1.1. Agents Used in the Different Exercise Types.................................................... 4 2.1. Choices of Exercise Templates.......................................................................... 6 2.2. Sample Template to Create a PowerPoint Slide................................................ 8 3.1. Sample Checklist...............................................................................................11 3.2. Balanced Exercise Facilitation...........................................................................12 4.1. Framework for Conducting an Exercise............................................................13 5.1. Plan-Do-Study-Act Framework ........................................................................18 vi Summary Major public health emergencies like bioterrorism are fortunately rare. The rarity of these events, however, makes it necessary for us to develop strategies that enable public health agencies to prepare for these emergencies in lieu of the pragmatic knowledge and experience that come from regularly responding to real events. Other agencies that deal with unforeseen emergencies such as agencies dealing with natural disasters (e.g., Federal Emergency Management Agency) and agencies dealing with the handling of nuclear materials (e.g., Nuclear Regulatory Commission) regularly use exercise methodologies, including tabletop exercises, as tools to assess their preparedness for emergencies and to train staff in how to respond appropriately to emergencies. Until recently, the use of tabletop exercises in public health has been fairly rare. This is in part because public health agencies, unlike many other agencies like fire departments that respond to emergencies, have multiple roles in the community other than solely responding to emergencies and have not had as much time to focus on preparedness exercises. For example, these agencies are often in charge of managing a community’s public health records, providing medical services such as immunizations, and managing public information campaigns for things like smoking cessation or healthy lifestyles. Therefore, responding to emergencies represents only a small part of the work of public health agencies and usually comes at the expense of the agencies’ other tasks. Since September 11, 2001, and the subsequent anthrax attacks, the use of tabletop exercises in public health has significantly increased. The evidence base for these exercises, however, remains sparse and the quality of many of these exercises is poor because they were not sufficiently beta tested. Most of these exercises focus on training and few provide public health agencies with tools to assess exercise performance. This narrow focus limits the ability of public health agencies to use tabletop exercises as part of an overall continuous quality improvement effort. In 2003, the U.S. Department of Health and Human Services Office of the Assistant Secretary for Public Health Emergency Preparedness contracted with the RAND Corporation to develop and beta test a suite of tabletop exercises that focus on the response of local public health agencies (LPHAs) to outbreaks caused by bioterrorism in the first few hours to days of the response. This book is the operations manual developed from that project. The tabletop exercises described in this manual were developed as templates that LPHAs across the country can customize and use to train public health workers in how to detect and respond to bioterrorism events and to assess the level of preparedness of LPHAs over time. They were beta tested and refined in 13 LPHAs across the United States over the course of 10 months. The manual outlines everything the leadership of an LPHA needs to do to plan for and conduct an exercise. The exercises are led by a trained facilitator. The facilitator guides the exercise discussion and provides exercise participants with probes to keep the vii discussion on track and moving forward. Checklists are provided as tools for facilitators to use to help structure the discussion and to assess the exercise. Chapter Three provides detailed information and training materials to teach individuals how to become effective exercise facilitators. All of the tabletop exercises outlined in the manual share five common elements that are described in detail in Chapter Two: (cid:120)(cid:3) initial situation reports (cid:120)(cid:3) case reports (cid:120)(cid:3) facilitated discussion (cid:120)(cid:3) situation updates (cid:120)(cid:3) hot wash. LPHAs can choose from a suite of exercises that focus on one of five potential bioterrorism agents: (cid:120)(cid:3) smallpox (cid:120)(cid:3) plague (cid:120)(cid:3) botulism (cid:120)(cid:3) anthrax (cid:120)(cid:3) novel (severe acute respiratory syndrome [SARS]-like) agent. The exercises focus on these agents because they have been identified in the literature as agents that represent our most significant risks, illuminate how the public health system would be taxed in a variety of bioterrorism events, and stimulate a broad range of bioterrorism preparations. Once an LPHA decides on an agent for its exercise, it can choose between four short (two hours), four medium (four hours), and one long exercise (six hours). Short exercises focus on topics of surveillance and detection and diagnosis and investigation while medium exercises go beyond these topics to discuss system wide coordination, risk communication, and disease control. The long exercise adds one final topic not covered in the short or medium exercises: consequence management. After an exercise has been conducted, the manual outlines strategies for assessing exercise performance in Chapter Four. The final chapter of the manual discusses how to incorporate the regular use of tabletop exercises into a continuous quality improvement framework for public health preparedness. viii