View
216
Download
0
Category
Tags:
Preview:
Citation preview
Bio-Security 2007Table Top Exercise in JAPAN Lessons from the Exercise
Presented by Mitsuyoshi Urashima MD, PhD, MPH
scene
Central Government(observer)
M. Health*1Foreign Affaires*2
Police*4
Defense*3
Infectious disease*10
Local Government*8
Media
Central
overseasCDCWHO:
Public health center*9
BusinessAirportAviationRailroad CoSubway CoAmusement ParkHotelsPharmaceutical Co.Travel agencyDepartment store etc
Transport*7
Hospitals First respondersFirePolice
Japanese Embassy in foreign countries
200 personnel: Not only LE/PH but Others
School
Control Room
Live Broadcasting
Mes
sen
ger
s
Hospital A Pharmaceutical Co
M of HealthNIID
Foreign Affairs
DefensePrefecture Tokyo
PH centerFire Dep
Media
AirportAviation
Transport
Tokyo Disney LandHotelTravel agency
Hospital B
Hospital C
Police
Prefecture ChibaPH centerFire Dep
Phone Phone
On the same floor15 small rooms: Each organism1 large room: Monitor and Control
Interview
No noticeReal role playPlayer drivenInjectLive broadcasting
monitoringall rooms by videorrding
Central Government(observer)
CO2 incubator for Cell culture
Clean bench
Culture media
Scenario: opened to participants after exercise and before workshop
SARS virus: CDC category C
Anthrax: CDC category A
Earth Earth UndergroundUnderground
TUSK on the EarthTUSK on the Earth
Arrival: Two tourists were infected here and each visited hospital A and hospital B.
Departure: One tourist was infected here and got sick in Singapore.
Many workers got inhalation anthrax by exposure to the spores at the fish market. Moreover, a person who never visited the fish market got intestinal anthrax by eating fish traded there.
Injecting InformationMinistry of Foreign Affairs
Sep 17: Anti-globalization activist: plan for demonstration by extremists during G8 Tohyako summit, by the Japanese Embassy in Germany (telegraph) FALSE
Sep 19: Extremists: possibility of bioterrorism in Japan, by the Japanese Embassy in Afghanistan (telegraph) FALSE
Sep 23: Vials containing SARS virus derived from super spreader kept in a research institution were stolen: still possibility, by the Japanese Embassy in Singapore (telegraph) TRUE
Sep 23: A Japanese tourist admitted to hospital due to severe respiratory disease, by the Japanese Embassy in Singapore (telegraph) TRUE
If these information were passed to Ministry of Health, it could be easier to suspect SARS but not avian flu.
Injecting InformationNational police agency
Sep 17: The same threatening letters by genuine defense/animal liberation fighters: “TUSK on the Earth” were sent to three fish food restaurants: Warning blast: The cancellation stamp was Toronto, Canada. TRUE
Sep 20: Threatening letter to sports stadium: Which was confirmed as cat copy of “TUSK on the Earth”. FALSE
Sep 22: Advance warning : Death to the Minister of Agriculture, Director-General of Fisheries Agency, and Minster of Environment to each major media by fax. TRUE
scene
Central Government(observer)
M. Health*1 Foreign Affaires*2Police*4
Defense*3
Infectious disease*10
Prefectural Government*8
MediaAvian FluOutbreaksIn Indonesia
Central
overseasCDCWHO: Avian Flu: Considering up-phase from 3 to 4 in Indonesia
Public health center*9
BusinessAirportAviationRailroad CoSubway CoAmusement ParkHotelsPharmaceutical Co.Travel agencyDepartment store etc
Transport*7
Hospitals First respondersFirePolice
Index case AB from Indonesia
Hospital AHospital B
Japanese Embassy in foreign countries
Threat of terrorismRobbery of SARS vials
Injecting InformationUniversity Hospital A
Sep 17: A Japanese branch manager (62 years old male) in Indonesia had returned to Japan at September 11th, and signs of influenza like illness progressed. Although he had been followed as common cold by a family doctor, his condition was getting worse and he became aware of dyspnea. Then, he admitted to University Hospital A. He died at September 21st, and the diagnoses were non-specified pneumonia plus cardiac failure. Sep 23: First patient’s son (28 years old male), who stayed and cared his father at the hospital A, got similar symptoms, and visited ER of the hospital A with his sister (26 years old, female), who had sometimes cough. Because all the beds were occupied of the hospital A, he needed to stay at ER for overnight. He was treated with oxygen, inhalation and drip infusion.
Index Case
Son of index case
Pat 1( 62Y )
Pat 2( 60Y )
Pat 8( 7 8Y )
Pat 7( 37Y )
Pat 3( 28Y )
Pat 5( 24Y )
Pat 6( 27Y )
Pat 4( 26Y )
Nurse: Contact with pat 3 & pat 4 at the hospital
Patient:Contact with pat 2 at ER
Visit Family A
9/13 onset9/21 death
9/21 onset9/26 death
University Hospital A
9/28 onset
9/26 onset
9/23 onset 9/23 onset
9/22 onset
infant
Wind Tower
Family A
Injecting Information
Ref. N Engl J Med. 2003 May 15;348(20):1995-2005.
Pat 1Male 35Y
death
Pat 2Female 32Y
Pat 3Female 32Y
Nurse
Pat 4Male 70Y
Wife
Contact at waiting room of hospital B
Staying at the sameFloor of the same hotel
Pat 5Female 33Y
Nurse
Pat 7Female 47Y
Nurse
Pat 6Female 38Y
Nurse
Pat 8Female 54Y
Nurse
Pat 10Male 56Y
Pat 9Male 50Y
Care pat 2 at ICUfor 6 hours
Care pat 4 at bedside
Met pat 4 at hotel and hospital
Same clinical ward with pat 4
University Hospital B9/17 onset9/21 death
9/21 onset
9/25 onset
9/21 onset
Injecting Information
Ref: N Engl J Med. 2003 May 15;348(20):1977-85.
Tokyo Disney Land
ship is available
but takes long time to reach,
Hotel
Narita International Airport
Singapore
All over Japan
Clinic
A Japanese tourist
An Indonesian tourist
Exposure
Exposure
Exposure
HospitalsExposure
Mikura island
where far from main island
do not have airport
but heliport.
愛
愛
High school
Wind Tower
Wind tower
Ho
sp A
Junior High school
Elementary school
University Hospital A
Injecting InformationTokyo prefecture
Sep 20: Phone call from a doctor of Mikura island: 6 family members have got serious pneumonia who came back from Tokyo Disney Land. 7 neighbors started fever and cough, still not serious yet. Carrying these patients by ship is danger and would you consider sending a helicopter?
Sep 24: Phone call from health consulting office at Wind Tower with 42 stories: 5 residents are state of respiratory distress. All hospitals nearby rejected due to no beds available. Would you seek hospital beds for us?
Sep 25: Phone call from health consulting office at Wind Tower: We’ve got a problem. Many of residents are complaining high fever and dyspnea. They have little connection within the Tower, thus infectious agents were disseminated through air. We have approximately 700 residents in this Tower and 10% are now sick, which is more than 10 times of yesterday.
Tokyo prefectural government
Influenza in IndonesiaPandemic? News
Threat letter against fish food shop
central gov.
Local fire department
Anthrax case in Hosp C: News
Pneumonia outbreak at Mikura IslandFrom Tokyo Pref.
Local public health
Chiba PrefAnthrax?
Central Gov.
Suspect Avian Flu
MikuraDispatch staff
Governor appealed Self-imposed control
Department store
Japan Rail
Media
Fire department
Hospital B: Need more staff
Ministry of Health
Wind Towerquarantine
Self-Defense Forces
Helicopter
Outbreaks in Hosp A, B and Wind Tower: News
Central Gov.
Dispatch medical staff with helicopters of self defense forces to Mikura: Consider quarantine whole island
central gov.
Media
Media
Office of Emergency Management
Overt terro
Injecting InformationDistrict General Hospital C
Sep 17: 72 years old male transferred to ER of District General Hospital C by ambulance for fever, chest pain in swallowing and dyspnea. The diagnosis was mediastainal abscess, of which chest x-ray findings are similar to those of inhalation anthrax. Players of hospital C did not showed any reactions to this case.
FALSESep 19: 56 years old fisherman visited for District General Hospital C for fever, cough and dyspnea. Players of hospital C did not showed any reactions to this case, too.
TRUE
Sep 22: Phone call from laboratory: Gram positive rods were detected in spinal fluid and blood of second patient, suspecting Bacillus Anthracis. Although the appearance of the organism was certainly consistent with another bacillus species, such as B. cereus or B. subtilis, these pathogens would not have been expected to be found in an otherwise healthy man. Thus, the case of fisherman was suspected inhalation anthrax and hospital C informed it to a local
public health center. Index case’s wife and five other patients who were in the fish market at 9 11th visited the hospital for
respiratory symptoms.
Injecting InformationDistrict General Hospital C
Sep 23: Results from drug sensitivity analysis phone and fax by laboratory.
Cipro and penicillin were sensitive.
Sep 25. 25 years old male visited the hospital for abdominal pain and distension. 10 days ago, he ate fish meat bought at a fish shop, but never been to fish market. After operation, he recovered. His diagnosis was confirmed as intestinal anthrax.
Ciprofloxacin <0.06*Rifampin 0.5*Tetracycline 0.06*Vancomycin 1-2* Penicillin <0.06**Clindamycin <0.5*Chloro 4*
This episode suggest that fish meat traded at the fish market September 11th is a risk for intestinal anthrax. All the fish meat should be traced and if it is too late, someone has to decide whether antibiotics are distributed to the people at risk as a post exposure prophylaxis and what extent.
Scenario of Anthrax attack
Hospital C
Public health side Law enforcement side
Local public health center
Prefectural government
Ministry of health
Local police office
Prefectural Police: NBC unit
National police agency
central gov.
Media
Expected: Observed:
offer
accept
pharmaceutical company
Chiba prefectural government
Influenza in IndonesiaPandemic? News
Threat letter against fish food shop
Local public health
Local police office
Anthrax case in Hosp C: News
Travel agency
Media
Pneumonia outbreak at Mikura IslandFrom Tokyo Pref.
Local public healthHotelHospital B
Local public health
Disney LandMinistry of Health
Mayor of city
Recognized Anthrax
Hospital B
Recognized outbreak of unknown origin:Suspect Avian Influenza
Media
Office of Emergency Management Media
Local police officeDispatch NBC unit
Media
Stadium: white powder
Fire department
Hospital B: Need more staff
Ministry of Health
Local police officeDispatch NBC unitDecontamination
Self-Defense Forces
Ministry of Healthcentral gov.
Recognized SARS
Local public health
central gov.
DMAT
Fire d
Tokyo
A secret base of terrorist: News
Overt Terrorism
Press Conference
central gov.Ministry of HealthMinistry of Foreign AffairesMinistry of internal affairs and communications
MediaJournalist
Live broadcasting
Terrorist group: earth underground; “TUSK on the Earth” declared bioterrorism using SARS virus and anthrax, which included information known only by criminals.
scene
Central Gov
M. Health*1 Foreign Affaires*2Police*4
Defense*3
Infectious disease*10
Prefectural Government*8
Media
Central
overseasCDCWHO:
Public health center*9
BusinessAirportAviationRailroad CoSubway CoAmusement ParkHotelsPharmaceutical Co.Travel agencyDepartment store etc
Transport*7
Hospitals First respondersFirePolice
Japanese Embassy in foreign countries
Epidemic of SARS
We’ve got a problem.
Hospitals are critical.
Nosocomical InfectionMaybe….
Outbreak of respiratory disease caused by unknown origin
Process Information Degradation of Information: SARS case
scene
Central Gov
M. Health*1 Foreign Affaires*2Police*4
Defense*3
Infectious disease*10
Prefectural Government*8
Media
Central
overseasCDCWHO:
Public health center*9
BusinessAirportAviationRailroad CoSubway CoAmusement ParkHotelsPharmaceutical Co.Travel agencyDepartment store etc
Transport*7
Hospitals First respondersFirePolice
Japanese Embassy in foreign countries
Epidemic of Anthrax
We have many patients with anthrax. They can be exposed to anthrax spore at fish market.
There are many patients with anthrax.
Perhaps, some patients are suspected anthrax.
There are patients with anthrax.
Process Information Degradation of Information: Anthrax case
Process Information
Doctors tended to
1) concentrate their attention on diagnosis and treatment of patients: do not know what’s going on in surrounding area and nation;
2) do all operations by themselves: do not ask for help;
3) do not have press conference.
Recommended