Interactive EventInteractive Event

Condensed Table Top ExerciseCondensed Table Top ExerciseFor San Joaquin CountyFor San Joaquin County

Adapted from an exercise by Adapted from an exercise by CDFA, CDHS, FDA and othersCDFA, CDHS, FDA and others

Monday June 5Monday June 5

9-11:00pm – San Joaquin General 9-11:00pm – San Joaquin General Hospital ER receives seven unrelated Hospital ER receives seven unrelated children with difficulty reading, children with difficulty reading, slurred speech & choking on evening slurred speech & choking on evening meal.meal.

Presumptive diagnosis is botulismPresumptive diagnosis is botulism What happens next?What happens next?

Tuesday June 6Tuesday June 6

8:00 am 8:00 am – Most ER’s in San Joaquin and – Most ER’s in San Joaquin and Sacramento Counties are seeing an Sacramento Counties are seeing an increase in pediatric patients & some increase in pediatric patients & some adults. Similar symptoms reported, adults. Similar symptoms reported, including dizziness, fatigue, dry mouth, including dizziness, fatigue, dry mouth, and double vision. and double vision.

10 am Conference Call Scheduled – Who 10 am Conference Call Scheduled – Who needs to be there?needs to be there?

Work Group Discussion # 1Work Group Discussion # 1

Based on information provided Based on information provided discuss:discuss: What is going on?What is going on?

Any suspect cause or causes?Any suspect cause or causes?

Who are involved in response?Who are involved in response?

Record answers on flip chartRecord answers on flip chart

Inject 1: Tuesday , June 6, Inject 1: Tuesday , June 6, 9:00am9:00am

First Cases –

Additional cases reported-

First Conference Call: Tuesday, First Conference Call: Tuesday, June 6, 1100 hoursJune 6, 1100 hours

Roll-call Roll-call

County public health (San Joaquin and County public health (San Joaquin and Sacramento counties), CDPH-DCDC, Sacramento counties), CDPH-DCDC, CDPH-FDB, CDC, FDA CDPH-FDB, CDC, FDA

Anyone Missing - If so, How do you reach Anyone Missing - If so, How do you reach out? (Are your contact lists current?)out? (Are your contact lists current?)

First Conference Call Tuesday, First Conference Call Tuesday, June 6, 11:00 amJune 6, 11:00 am

Review descriptive epidemiologyReview descriptive epidemiology Many cases are childrenMany cases are children Some of the adult cases work in schoolsSome of the adult cases work in schools No common event reportedNo common event reported Tentatively classified as food-borneTentatively classified as food-borne

Local and state epidemiologists are working Local and state epidemiologists are working round the clock to conduct interviewsround the clock to conduct interviews

The media is calling county and state public The media is calling county and state public health departments seeking informationhealth departments seeking information

Concern expressed that this was an intentional Concern expressed that this was an intentional contamination eventcontamination event

Summary of content of case Summary of content of case investigation form for neurologic investigation form for neurologic

illnessillness

Demographic informationDemographic information Signs and symptomsSigns and symptoms Past medical and social historyPast medical and social history Hospital infoHospital info Physical examPhysical exam Lab test resultsLab test results Initial treatmentInitial treatment Discharge informationDischarge information

Summary of content of case Summary of content of case investigation form for neurologic investigation form for neurologic

illnessillness Risk exposure questionsRisk exposure questions

Pertain to 2-week period prior to onsetPertain to 2-week period prior to onset Describe your job/volunteer dutiesDescribe your job/volunteer duties Anyone else at your workplace have Anyone else at your workplace have

similar symptoms?similar symptoms? Do you know anyone else with similar Do you know anyone else with similar

symptomssymptoms Travel?Travel? Public functions attended?Public functions attended? Types of transportation usedTypes of transportation used

Summary of content of case Summary of content of case investigation form for neurologic investigation form for neurologic

illnessillness Food and beverage questionsFood and beverage questions

Types of food establishments where Types of food establishments where food consumedfood consumed Time and place, food consumed for Time and place, food consumed for

eacheach Any free food samples?Any free food samples? Any supplements?Any supplements? Unpasteurized products?Unpasteurized products? Mail order foods?Mail order foods? Water sourcesWater sources

Tuesday June 6 at 3:00 pmTuesday June 6 at 3:00 pm

Number of ill is rising rapidlyNumber of ill is rising rapidly Law enforcement has been informed of possible Law enforcement has been informed of possible

tamperingtampering Largest number of ill are in 5-18 year old age groupLargest number of ill are in 5-18 year old age group Hypothesis-generating interviews indicate that the Hypothesis-generating interviews indicate that the

common exposure of most of the children was common exposure of most of the children was eating lunch at schooleating lunch at school

Some adults report eating lunch at school, others Some adults report eating lunch at school, others ate at a deli chain that serves the Sacramento areaate at a deli chain that serves the Sacramento area

Epidemiologists are reviewing school lunch menus Epidemiologists are reviewing school lunch menus for schools of affected children and developing a for schools of affected children and developing a questionnairequestionnaire

Wednesday June 7Wednesday June 7

Some patients experiencing respiratory difficulty. Some patients experiencing respiratory difficulty. Additional respirators requested by hospitals.Additional respirators requested by hospitals.

Number of ill now exceeds 500. Additional Number of ill now exceeds 500. Additional antitoxin requested from CDC.antitoxin requested from CDC.

Worried parents are bringing children to Worried parents are bringing children to emergency rooms that are not seriously ill.emergency rooms that are not seriously ill.

911 lines are overloaded911 lines are overloaded 2:30 pm - 3 deaths reported2:30 pm - 3 deaths reported Epi results indicate milk is possible vehicle. Epi results indicate milk is possible vehicle.

Conference call scheduled for 3 pm. CDFA and Conference call scheduled for 3 pm. CDFA and FBI invited to join.FBI invited to join.

Work Group Discussion # 2Work Group Discussion # 2 Based on information provided Based on information provided

discuss:discuss:

Next steps?Next steps? What information should be provided to What information should be provided to

the public?the public? What is my organization’s role?What is my organization’s role? How do I provide assistance if not How do I provide assistance if not

directly involved?directly involved? Who is involved in response? Who needs Who is involved in response? Who needs

to be involved, but isn’t?to be involved, but isn’t?

Inject 2: Conference call Inject 2: Conference call Wednesday June 7 at 3 pmWednesday June 7 at 3 pm

Epidemiology reviewedEpidemiology reviewed

Third Conference Call Thursday Third Conference Call Thursday June 8, 0630June 8, 0630

Roll-CallRoll-Call New informationNew information

In San Joaquin County most victims had consumed milk at In San Joaquin County most victims had consumed milk at schoolsschools

Low fat milk in ½ pints were consumed at schoolsLow fat milk in ½ pints were consumed at schools Other victims had consumed either low fat or reduced fat milkOther victims had consumed either low fat or reduced fat milk Whole milk did not appear to be implicatedWhole milk did not appear to be implicated Incriminated milk had one sell-by dateIncriminated milk had one sell-by date Incriminated milk had one plant ID#Incriminated milk had one plant ID# Plant # belongs to a new plant in San Joaquin CountyPlant # belongs to a new plant in San Joaquin County

((Note:Note: Next 5 Slides are Reference Slides for Badger Creek Milk) Next 5 Slides are Reference Slides for Badger Creek Milk)

Reference Slide 1: Fictional Milk Reference Slide 1: Fictional Milk ProcessorProcessor

NameName: Badger Creek Milk Co.: Badger Creek Milk Co.

LocationLocation: Lodi, CA: Lodi, CA

Company goalCompany goal: Become a leader in the : Become a leader in the California organic milk marketCalifornia organic milk market

Plant DescriptionPlant Description: Moderate sized, Grade A : Moderate sized, Grade A facility. Fluid milk bottling with an on-site facility. Fluid milk bottling with an on-site evaporatorevaporator

Reference Slide 2: Fictional Milk Processor Reference Slide 2: Fictional Milk Processor Badger Creek Milk Inc.Badger Creek Milk Inc.

Milk SupplyMilk Supply: Purchases milk from 25 local organic dairies, : Purchases milk from 25 local organic dairies, and a California based dairy cooperativeand a California based dairy cooperative

Customers IncludeCustomers Include::1. California State University, Sacramento1. California State University, Sacramento2.2. Stockton, Tracy, Lodi, Manteca, and Elk Grove Unified Stockton, Tracy, Lodi, Manteca, and Elk Grove Unified School DistrictsSchool Districts3.3. National made to order sandwich chain (“Deli”)National made to order sandwich chain (“Deli”)

   Surplus cream and condensed sold to largeSurplus cream and condensed sold to large

San Diego manufacturing plantSan Diego manufacturing plant

Reference Slide 3: Badger Creek Milk Reference Slide 3: Badger Creek Milk Co., Plant DiagramCo., Plant Diagram

Raw MilkSilo 2

Raw MilkSilo 3

HTSTPasteurizer

Past.storageTank 1

Past.storageTank 2

Past.storageTank 3

FillersPackaging

Evaporator

Warehouseand

DistributionBulk

Loadout

CreamTank

BulkLoadout

CondensedTank

Raw MilkSilo 1

CreamTank

BulkLoado

ut

Reference Slide 4: Low Fat Milk made Reference Slide 4: Low Fat Milk made for Schools and Delifor Schools and Deli

Sunday June 4, 11:00 pm: Used 17,200 gal Sunday June 4, 11:00 pm: Used 17,200 gal of raw milk Silo A (uncontaminated) and of raw milk Silo A (uncontaminated) and 1,041 gallons of condensed to produce: 1,041 gallons of condensed to produce:

1,255 gal of cream1,255 gal of cream

16,985 gal of low-fat milk16,985 gal of low-fat milk((160,000 half pints for schools160,000 half pints for schools))(111,776 half pints for Deli)(111,776 half pints for Deli)

Reference Slide 5:Reference Slide 5:Production Production DetailsDetails

Milk received 7 days/week, used within 24 to 48 Milk received 7 days/week, used within 24 to 48 hours.  hours.  

All school districts purchase half pints of Lowfat All school districts purchase half pints of Lowfat milkmilk

Deli purchases half pints of whole milk, reduced Deli purchases half pints of whole milk, reduced fat milk, and lowfat milkfat milk, and lowfat milk

Half pints are produced Sunday and Wednesday Half pints are produced Sunday and Wednesday (distributed Monday and Thursday)(distributed Monday and Thursday)

Third Conference Call Thursday Third Conference Call Thursday June 8 0630June 8 0630

Topics during call:Topics during call: Any remaining half-pints of milk must be embargoed Any remaining half-pints of milk must be embargoed

immediately. How will this be done?immediately. How will this be done? Might consumers have this product in their Might consumers have this product in their

refrigerators?refrigerators? The good news is that only one plant appears involved The good news is that only one plant appears involved

(at this time). Consumers who do not have this brand (at this time). Consumers who do not have this brand (and sell by date) need not be concerned. (and sell by date) need not be concerned.

How do you convince consumers that the problem is How do you convince consumers that the problem is not more widespread? How can we be sure that no not more widespread? How can we be sure that no other product is contaminated? (Whole milk involved?)other product is contaminated? (Whole milk involved?)

Inject 3: Inject 3: Work Group Discussion # 3Work Group Discussion # 3

Fourth Conference Call Thursday Fourth Conference Call Thursday June 8, 11:30June 8, 11:30

Roll-Call - Roll-Call - Topics for this callTopics for this call Situation updateSituation update What do you do with the remaining suspect milk What do you do with the remaining suspect milk

(in plant, at distributors, at retail, in homes, in (in plant, at distributors, at retail, in homes, in disposal bins at schools or elsewhere)?disposal bins at schools or elsewhere)? Collection and disposal issuesCollection and disposal issues

How can you handle uncontaminated yet How can you handle uncontaminated yet unwanted milk from the unaffected dairies and unwanted milk from the unaffected dairies and plants? plants?

Are there safety precautions necessary when Are there safety precautions necessary when handling contaminated milk or containers? handling contaminated milk or containers?

What needs to decontaminated and how? What needs to decontaminated and how? How can it be destroyed? How can it be destroyed? (Note: Situation update is summarized next 2 (Note: Situation update is summarized next 2

slides)slides)

Info Presented on Call –Info Presented on Call –Deaths by City up to 10:30 AM on June Deaths by City up to 10:30 AM on June 8th8th

City Wednesday by 6:00 PM

Thursday by 10:30 AM

Total

Elk Grove 20 210 230

Stockton 37 347 384

Tracy 10 225 235

Lodi 11 144 155

Sacramento 3 182 185

Total 81 1108 1189

Deaths by Age-Group and Deaths by Age-Group and CityCity

City/Age <5yrs 5-18yrs >18 years Total

Elk Grove 37 112 81 230

Stockton 42 315 27 384

Tracy 14 193 28 235

Lodi 25 98 32 155

Sacramento 3 57 125 185

Total 121 775 293 1189

Inject 4: Work Group Inject 4: Work Group Discussion (4)Discussion (4)

LABORATORYLABORATORY

RESPONSE & RECOVERYRESPONSE & RECOVERY

RESPONSE TO EVENTRESPONSE TO EVENT

Who calls in the Labs & What Lab Who calls in the Labs & What Lab support is needed?support is needed?

CapabilityCapability : : Who can handle & analyze samples?Who can handle & analyze samples? Which Food Testing Laboratories ? Which Food Testing Laboratories ?

Capacity:Capacity: How many Samples? How many Samples? Which Product(s)?Which Product(s)?

RESPONSE –con’t RESPONSE –con’t

Based on Current information:Based on Current information: Capability : Capability :

Only 5 Food testing labs available in CA can Only 5 Food testing labs available in CA can analyze milk samples.analyze milk samples.

Lab Locations:Lab Locations: Davis (CAHFS), Alameda (FDA), Irvine (FDA),Davis (CAHFS), Alameda (FDA), Irvine (FDA), Fresno (County PHL) , Richmond (CDHS-FDLB)Fresno (County PHL) , Richmond (CDHS-FDLB)

RESPONSE –con’tRESPONSE –con’t

Capacity:Capacity: Davis, Fresno, Richmond, Irvine can Davis, Fresno, Richmond, Irvine can

analyze 25 samples in a 24hrs period analyze 25 samples in a 24hrs period (100/day for 4 days)(100/day for 4 days)

Alameda Lab has same capacity as Alameda Lab has same capacity as other labs, but Instrument is down & other labs, but Instrument is down & Won’t be back on-line for 5 days. (from Won’t be back on-line for 5 days. (from 6/13 Capacity will be 125 samples a 6/13 Capacity will be 125 samples a day)day)

RECOVERYRECOVERY

What Lab support will be needed to What Lab support will be needed to work thru this phase?work thru this phase?

Assume Capacity is sameAssume Capacity is same Do we need more labs? Do we need more labs?

If so – How will you obtain or access If so – How will you obtain or access additional Laboratories?additional Laboratories?

What Lab networks are out there?What Lab networks are out there?

Inject 5 -Work Group Discussion Inject 5 -Work Group Discussion Lab Questions “?’s”Lab Questions “?’s”

Summarize InfoSummarize Info

Group Discussion Group Discussion

Badger Creek Milk Inc. Badger Creek Milk Inc. Event OverviewEvent Overview

2,500 gallons of raw milk in a dairy farm tank 2,500 gallons of raw milk in a dairy farm tank was contaminated with 2 grams pure botulinum was contaminated with 2 grams pure botulinum toxin, type A toxin, type A