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Acronyms
ACFS acute complex feline syndrome
APSED III Asia Pacific Strategy for Emerging Diseases and Public
Health Emergencies
EIS event information site
EOC emergency operations centre
IHR International Health Regulations
NDPH National Department of Public Health
NEMO National Emergency Management Office
NFP National IHR Focal Point
PHEIC public health emergency of international concern
RRT rapid response team
WHO World Health Organization
1.3 Objectives
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2. Methodology
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5
2.2 Exercise type
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2.3 Exercise design
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2.4 Exercise participants
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2.6 Exercise scenario
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3. Observations and recommendations
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3.1 Validate the accessibility of the National IHR Focal Points and
WHO IHR Contact Point using
registered contact details
.................................................................................................................
9
3.2 Practise and test IHR NFPs’ assessment of public health events
using the decision instrument
contained in Annex 2 of IHR (2005)
................................................................................................
10
3.3 Practise and test IHR NFPs’ understanding and use of IHR (2005)
principles and obligations . 11
3.4 Improve the understanding and familiarity of staff across
Member States and WHO with the
IHR NFP system
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12
3.5 Test the videoconferencing capability of the EOC in the WHO
Regional Office for the Western
Pacific and National IHR Focal Points in some selected countries
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Annexes
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Annex 2 – Scenario
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Annex 4 – Exercise schedule
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Annex 5 – Summary of participants feedback
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Annex 6 – Key statistics*
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Keywords
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Summary The World Health Organization (WHO) works with and supports
Member States to implement the International Health Regulations, or
IHR (2005). A key component of IHR implementation is communication
between National IHR Focal Points (NFPs) and the WHO IHR Contact
Point. It includes public health event reporting, notification,
verification, information-sharing and risk assessment. It may also
involve official communications required for the determination of a
public health emergency of international concern (PHEIC) and the
associated emergency response under IHR (2005). Annually, the WHO
Regional Office for the Western Pacific conducts a simulation
exercise involving NFPs and the WHO IHR Contact Point. IHR Exercise
Crystal 2017 was conducted on 5–6 December 2017. Participants from
mainly Pacific island countries and areas took part in the exercise
on 5 December, while those from mainly Asian countries participated
on 6 December. The exercise was conducted over five hours,
simulating the first 12 weeks of an outbreak. The exercise provided
a functional test of emergency systems, and participants were
required to undertake simulated emergency functions that reflected
their role in a real-life developing situation. Relevant WHO
country office staff supported participants as needed. Both Member
States and areas were invited to participate in this recent
exercise. The role of public health staff from areas differs from
that of NFPs, but they also play an important role in IHR
implementation. These participants were encouraged to follow
already-established lines of communication for public health
events. The simulation exercise is an important component of the
global IHR (2005) Monitoring and Evaluation Framework, which has
been embedded in the Asia Pacific Strategy for Emerging Diseases
and Public Health Emergencies (APSED III). Experience has shown
that it is a useful way to test IHR capacities and to prepare
countries to respond to real-life public health emergencies. The
2017 edition of IHR Exercise Crystal was the most successful to
date, with a record-breaking 30 countries and areas testing their
response to a fictional outbreak. Countries also demonstrated
increased understanding of, and comfort with, IHR communication. In
2011, for example, only five countries and areas notified WHO of
the simulated public health event within the expected time frame.
That figure rose to 26 in 2017.
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1. Introduction
1.1 IHR event communication The World Health Organization (WHO)
works with Member States to implement the International Health
Regulations, or IHR (2005). A key component of IHR implementation
is communication between National IHR Focal Points (NFPs) and the
WHO IHR Contact Point. It includes public health event reporting,
notification, verification, information-sharing and risk
assessment. It may also involve official communications required
for the determination of a public health emergency of international
concern (PHEIC) and the associated emergency response under IHR
(2005).
1.2 IHR Exercise Crystal An IHR Exercise Crystal has been conducted
almost every year since 2008 to maintain and strengthen the
functions of NFPs across the Region and to improve communication
between the NFPs and the WHO IHR Contact Point. The exception was
in 2009, when resources were instead directed to a real- life event
– pandemic influenza A(H1N1) 2009. The exercise in 2017 represents
the latest iteration of this process and is aimed at furthering
collaboration across the Region and familiarizing participants with
their duties and obligations under IHR (2005).
1.3 Objectives The objectives of IHR Exercise Crystal in 2017
were:
1) to validate the accessibility of NFPs and the WHO IHR Contact
Point using registered contact details;
2) to practise and test the NFPs’ assessment of public health
events using the decision instrument contained in Annex 2 of IHR
(2005);
3) to practise and test the NFPs’ understanding and use of IHR
principles and obligations; 4) to improve the understanding and
familiarity of staff across Member States and WHO with the
IHR NFP system and improve collaboration with other agencies, where
possible; and 5) to test the videoconferencing capability of the
Emergency Operations Centre (EOC) in the
WHO Regional Office for the Western Pacific and of NFPs in selected
countries.
2. Methodology
2.1 Scope of the exercise
In 2017, IHR Exercise Crystal continued to focus on practising and
testing participants’ understanding and use of IHR principles and
assessment of public health events. The exercise continued the
theme of past exercises by testing the accessibility of NFPs and
participants from territories and areas to facilitate communication
and collaboration during an emergency event.
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2.2 Exercise type
IHR Exercise Crystal 2017, like previous years, was a modified
functional exercise, requiring NFPs and
WHO exercise participants (players) to respond to incoming
simulated event information and requests
in a timely manner. Participants received regular updates or
“injects” by email, signalling a potential
public health event in the participants’ own country, including
initial reports from a simulated local
public health unit, media reports on the event and situation
updates from affected areas. WHO staff
played the role of the WHO IHR Contact Point, contacting NFPs with
requests for more information
and other communication. The exercise required NFPs and players to
simulate the actions they would
normally perform, given the type of information received during the
exercise.
2.3 Exercise design The scenario for 2017 involved an unknown
emerging illness and its potential consequences. The exercise
encompassed many elements that have been identified as important
aspects leading to the outbreak of a disease with pandemic
potential. The initial scenario commences with an outbreak of an
unidentified illness in mammals (in this case, domestic and wild
cats). The virus then moves into the human population where it
spreads rapidly from human to human. Cases are identified away from
the site of the initial outbreak. The simulation continues to the
point where cases are reported outside of the initial country and
the WHO Director-General declares a PHEIC as defined by IHR (2005).
The exercise used a simulated, artificial scenario that may not
reflect a real-world situation, particularly with respect to the
disease itself and its spread or impact. Elapsed time, place names
and people were also artificial. The exercise was designed to raise
issues for discussion. The aim of any simulation exercise is to
help institutions learn by identifying strengths and shortcomings
in a safe environment and thus help them to prepare for a real
emergency situation. The exercise was designed to test
decision-making during the simulated event and methods of
communicating these decisions. Testing covered the use of
appropriate communication systems as well as the use of the IHR
event information site (EIS) online portal. The simulation
consisted of a number of problem statements (injects) that
participants addressed within their own country context. The
exercise was conducted over five hours. The first group, mainly
Pacific island countries and territories, participated on 5
December 2017. The second group, mainly Asian countries,
participated on 6 December 2017.
2.4 Exercise participants In 2017, an all-time high of 30 countries
and areas participated in the exercise. Both Member States
and areas were invited to participate in this exercise. The role of
public health staff from areas differs
from that of NFPs, but these participants also have important
contributions to make and were
instructed to follow already-established lines of communication for
public health events.
NFPs were encouraged to work within their existing teams and to
involve other staff members, as
appropriate. Most countries involved teams of three or more staff,
with some countries involving up
to 20–30 staff in one location. Other in-country staff simulated
their advisory and support roles and
demonstrated the utility of the NFP system, enabling countries to
draw on a significant pool of experts
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to support the NFP. WHO country office staff were encouraged to
join their national counterparts
during the exercise.
2.5 Exercise management team An exercise management team was
established within the WHO Regional Office to develop and
conduct the exercise. The team comprised an exercise director, a
lead controller, an exercise designer,
several simulators, the WHO IHR Contact Point, an evaluator and
administrative assistants. Relevant
WHO country office staff were encouraged to participate in the
exercise as observers and/or
facilitators to support the exercise management team.
2.6 Exercise scenario IHR Exercise Crystal 2017 was a
scenario-based, modified functional exercise requiring participants
to respond to simulated incoming event information and requests in
a timely manner. This included making decisions on actions
required, but not actually taking concrete action aside from
preparing situation reports or summary paragraphs for the EIS.
These actions were based on the type and nature of the information
received during the exercise, information that could reasonably be
expected in a real event. For the 2017 exercise, it was proposed
that the evolving situation should be first identified in the
participants’ own country. Previous exercises had the illness
commencing in a third, usually artificial country, but to add
urgency and realism, it was decided to examine how countries would
react to an outbreak on their own land. The decision to identify
the outbreak in the participants’ own country was agreed following
an analysis of previous exercises and a desire to shift some of the
exercise focus. By responding to an event in their own country,
rather than in a fictitious neighbouring country, participants were
able to discuss their own internal systems for early surveillance
and reporting. To keep within this context, cats were used as the
primary vector as they are common throughout all countries and
areas in the Region. Another aspect introduced was more modern
means of gathering information from communities. Alongside standard
surveillance methods, it was decided that an element of public
discourse through social media should be added. This is a
reflection of modern, real-world surveillance in which public
health authorities are beginning to make greater use of social
media to augment traditional methods. This is being used for
targeted events (for example, mass gatherings) as well as more
general surveillance (for example, mapping influenza spread).1 Key
elements of the simulation included the examination of internal
systems related to IHR (2005), such as notification, restrictions
on movement, travel and trade as well as transboundary
arrangements. Consistent with past exercises, IHR Exercise Crystal
2017 involved partner agencies from outside the traditional public
health sphere, such as:
1) veterinary and animal health departments; 2) national disaster
management agencies and authorities; and
1 Fung I C-H, Tse ZTH, Fu K-W. The use of social media in public
health surveillance. Western Pac Surveill Response J.
2015;6(2):3–6. doi:10.5365/wpsar.2015.6.1.019
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3) other related bodies depending on the country’s own emergency
management protocols (for example, the Prime Minister’s Office or,
in the case of territories, their parent public health
bodies).
The simulation concluded with the WHO Director-General declaring a
PHEIC and inviting participants to join a hot-wash debriefing. This
gave both the WHO Regional Office and participants the opportunity
to test videoconferencing and audioconferencing capacity. For IHR
Exercise Crystal 2017 new methods of video communications were
used, including the Zoom Platform (San Jose, CA, USA). Overall,
there was a high level of engagement in the exercise with most NFPs
involving their wider teams. Some NFPs took the opportunity to
engage staff and partners from the health sector at both the
national and local levels. Some NFPs also involved departments
outside the health sector and this was useful in testing some of
the engagement issues that were part of the exercise design. These
inclusions are encouraged as a mechanism for developing and
sustaining an understanding of IHR (2005) and enhancing the
capability of the NFP function. In the future, it would be useful
to contact these agencies in advance and encourage their
participation. This sentiment was echoed by some of the
participants during the short debriefing after the event.
2.7 Limitations As anticipated, some of the more remote and smaller
nations were not able to fully participate due to technical and
logistical challenges. However, a system of one-to-one
communication was established to communicate the exercise to these
participants. Consistent with previous exercises, there was limited
engagement directly between Member States with almost all
interaction being between WHO and the NFP in country. This is a
challenge for future exercises as this was raised as a limitation
by some groups. It will require more thought and possibly the use
of innovative technology and back-up options to ensure that the
exercise is managed sufficiently.
2.8 Exercise feedback and evaluation For evaluation purposes,
feedback from participants about their experience with the exercise
was
obtained by means of:
a short debrief to capture impressions immediately after the
exercise;
a debrief of the exercise team after both days of the
exercise;
observations of the designated exercise evaluator; and
evaluation forms submitted by participants after the exercise (a
summary of responses to
evaluation questions is in Annex 2).
3. Observations and recommendations
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This section presents results of the exercise, based on observation
during the exercise, and feedback
from observers and participating organizations through debriefing
and the feedback forms. The
findings and recommendations are summarized according to the
exercise objectives.
3.1 Validate the accessibility of the National IHR Focal Points and
WHO IHR Contact Point using registered contact details
The primary aim of IHR Exercise Crystal is to improve communication
and collaboration across the
Region in the event of a public health emergency as defined under
IHR (2005). The first area tested
was the contact information of all IHR NFPs. This was a process
that was largely carried out prior to the
exercise itself and required WHO Regional Office staff to contact
each IHR NFP directly and to confirm
that they were still the designated person and that the contact
details on hand were correct. By
undertaking IHR Exercise Crystal annually, it ensures that the
database of NFP contact information is
regularly updated. This is a highly beneficial part of the process
and ensures that the WHO Regional
Office for the Western Pacific has one of the most complete
databases of NFPs globally. It is important
to note that even in the interval of 12 months there are
significant changes to the NFP lists, and, as
such, a 12-month review should be considered the minimum interval
within which to verify contact
details. A six-month review would be of greater utility; however,
given time constraints (it typically
takes 1–2 weeks to verify the list), this may not be
practical.
Recommendation: Maintain the current 12-month review interval for
verifying NFP contact
details
In addition to verifying contact details, IHR Exercise Crystal in
2017 examined the performance of
various information and communication technologies to be used for
the communication between the
NFPs and WHO IHR Contact Point.
Access to various information and communications technologies
varied across the Region. In general,
participants in Pacific island countries and areas had limited
access to more advanced technologies.
This ranged from a lack of high-speed Internet connections through
to basics, such as reliable phone
lines and mobile services. Even with prior preparation for the
simulation exercise, many Pacific island
countries struggled to effectively connect and there were frequent
dropouts and service difficulties. As
part of the testing process, streaming services, particularly
YouTube was used to distribute some
material elements. In some countries, such as Tokelau and Tuvalu,
there was insufficient bandwidth to
stream even low definition video and it was difficult to move even
moderate file size packages. Given
these problems, transferring large amounts of data in an emergency
could prove challenging.
Traditional platforms, such as email provided a more consistent
result, although file sizes needed to be
managed.
Another challenge faced by some countries was the issue of content
filtering (that is, blocking access
to certain websites), which limited their ability to use platforms
such as Skype for communication or
YouTube for streaming. This was partially mitigated by using
applications generated by smaller
companies and using material hosted directly by WHO. For instance,
Zoom provided excellent results
for video communications and the WHO website was used for
interactive surveys rather than relying
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on blocked services such as Survey Monkey. In a future response, it
will be important for the WHO
Regional Office to properly scope what services can be used across
all Member States to ensure that
interoperability is not compromised.
Comments from participants included:
“We faced a technical problem using the microphone because it was
the first time to try the
videoconference for IHR Exercise Crystal.”
“Could not access some material [video] due to platform
problems”
The in-country communications procedures appeared to require
improvement in some countries.
While there is a consistent communication relationship between the
WHO IHR duty officers and their
IHR NFP counterparts, some countries mentioned that they would need
to improve communications
with animal health stakeholders and disaster management agencies.
This indicates that further
improvement of multisectoral coordination and communication
mechanisms for the implementation
of IHR(2005) appears critical in those countries.
Recommendations:
1. Provide more support and attention to Member States with limited
access to information and
communications technologies, particularly those located in the
Pacific. Examine innovative
ways of supporting communications during the emergencies.
2. Continue to explore innovative technologies that are low
bandwidth and available to use
across the Region. It may be worth considering a standard set of
communication and
collaboration tools.
3. Continue to encourage Member States to further enhance a
multisectoral approach in
managing public health emergencies, including the communication
procedures.
3.2 Practise and test IHR NFPs’ assessment of public health events
using the decision instrument contained in Annex 2 of IHR
(2005)
The exercise tested the use by the IHR NFPs of the decision
instrument contained in Annex 2 of IHR
(2005) by requiring participants to assess the simulated situation
and notify WHO when needed. These
requirements were generally well understood by participants,
particularly by those that had
participated in previous Crystal exercises (demonstrating the
utility of regular exercising). In 2017,
26 countries and areas notified WHO of the simulated public health
event within the expected time
frame, up from just five countries and areas in 2011.
Furthermore, use of the EIS was also practised. The simulation
required IHR NFPs to log into the
system and to report the situation. Most NFPs were able to
successfully log in; however, a significant
number of NFPs could not access the system. The causes were:
1. lack of familiarity with the login system;
2. expired or forgotten passwords;
3. staff who were new to the role and has not activated an account;
and
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4. staff who were based in areas significantly geographically
separated from their parent
countries (for example, Marshall Islands, American Samoa, New
Caledonia) and, as they are
not the NFP, they rely on their headquarters to keep them
informed.
These are issues that have been encountered in previous exercises
and, in general, are easy to fix with
the adequate support. Item 4 may require improved coordination
between the area and their parent
Member State and the procedures may require attention and
strengthening.
Part of the exercise required the drafting of a mock EIS post,
based on a risk assessment. This was
followed by an update to the risk assessment and feedback to the
WHO IHR Contact Point. Comments
from the participants demonstrated that this was a useful exercise.
Comments included:
“Yes, it was useful to try to draft EIS.”
“It provides the pathway towards information-sharing, the type of
information to be shared
and the channel of communication involved.”
While relatively simple, this exercise is important as it verifies
users’ ability to access and contribute to
the critical information-sharing system among IHR NFPs in a real
incident.
In relation to the EIS posting, there were some issues with
consistency, which could be addressed
through the use of a simple training tool and template.
Recommendations:
1. Examine whether it is possible to know who has access to EIS
within the Region (examine the
login system). This will enable the WHO Regional Office to
understand and update the list of
persons who have access to the system.
2. Provide further guidance as required in the form of an agreed
template for EIS posting to
promote consistency of the posting.
3.3 Practise and test IHR NFPs’ understanding and use of IHR (2005)
principles and obligations
Through participating in IHR Exercise Crystal, participants were
reminded of the IHR (2005) principles
and obligations. The principles include: that its implementation be
guided by the goal of applying full
protection of all people from the international spread of disease,
and that States have the sovereign
right to legislate and to implement legislation, in support of the
purpose of IHR (2005).
The participants were also reminded of the obligation to strengthen
their core capacities to implement
IHR (2005), including those for surveillance, risk assessment and
response. Under IHR (2005), State
Parties have to assess events by using the decision instrument in
Annex 2, and should notify WHO by
the most efficient means of communication available by way of the
IHR NFP, and within 24 hours of
assessment of public health information of all events which may
constitute a PHEIC, and any health
measures implemented in response to those events.
The exercise helped to reinforce these key obligations. Regular
refresher training using methods such
as IHR Exercise Crystal appears useful to deepen the understanding
of IHR (2005) principles,
obligations and instruments. Some participants commented as
follows:
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“[We were able to] read and understand the use of IHR principles
and obligations”
“[Used as an opportunity] to review the IHR (2005) Annex 2”
Recommendation:
Ensure that refresher material is provided at least annually.
Exercise Crystal is the perfect opportunity
for this as it is directed specifically at IHR NFPs.
3.4 Improve the understanding and familiarity of staff across
Member States and WHO with the IHR NFP system
Over the years, IHR Exercise Crystal has contributed to improving
the understanding and familiarity of
staff across Member States and WHO with the IHR NFP system. Through
exercises during peacetime,
staff deepen their understanding of how IHR NFPs function, and how
communication should be
organized. Such understanding is expected to facilitate
communication between IHR NFPs and the
WHO IHR Contact Point in real events.
Furthermore, the exercise in 2017 aimed to strengthen understanding
of the role of NFPs to establish
in-country communication procedures and mechanisms with other
in-country stakeholders. Similar to
the Crystal exercise in 2016, it involved information-sharing and
decision-making in collaboration with
other agencies such as those in charge of animal health, and the
National Disaster Management
Authority or Agency (NDMA) of the participating country. In this
exercise, it was simulated, with the
only required information from the participants being the contact
details of the relevant agencies (in
this case, ministries of agriculture and the NDMA, or equivalent).
Several countries actually invited
members of the NDMA; in some other countries, animal health
officials were also present. While this
was not required by the simulation, such cooperation between
agencies should be encouraged.
Comments from participants included:
“Identified opportunity - that the exercise could have been
improved if we had engaged a broader
section of the government agencies within [Country T], beyond the
ministry of health, health
inspectors…”
Recommendation:
For future exercises, invitations should be sent well in advance
and include invitations for other
agencies, such as the NDMA, agriculture, and other relevant
sectors, as determined by the respective
participating country’s emergency management plan and legislation,
and depending on the nature of
the exercise scenario.
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3.5 Test the videoconferencing capability of the EOC in the WHO
Regional Office for the Western Pacific and National IHR Focal
Points in some selected countries
The videoconferencing tool used for the “hot wash” debrief at the
end of the exercise exceeded
everyone’s expectations. In 2016, the facilitation team attempted
to use in-house technology that
relied on the limited bandwidth of the WHO Regional Office for the
Western Pacific in Manila.
For 2017, a cloud-based system (Zoom) was utilized, which was low
bandwidth at the point of receipt
(connections are handled upstream). This resulted in the ability of
a large number of participants to
participate in the hot wash. At one point, 18 simultaneous
connections were established and the
debriefing was carried out with little interruption. The technology
was simple to use, operating
through users’ own computers, negating the need to purchase
expensive dedicated communications
equipment. Low bandwidth countries such as Solomon Islands and
Tonga were also able to participate
effectively.
Recommendation:
Based on the excellent experience with videoconferencing gained
this year, stakeholders should
continue to explore technology options that can improve IHR
communications, particularly with
countries with limited information technology infrastructure.
Annexes
Introduction
The Asia Pacific Strategy for Emerging Diseases and Public Health
Emergencies (APSED
III) was developed as a common regional framework for action and
provides a step-wise
approach for Member States to achieve the core capacities required
under International
Health Regulations (IHR) (2005). Ensuring the functions of IHR
(2005) National Focal
Points (NFPs) and the WHO IHR Contact Point, including IHR event
communications, has
been an essential component of IHR (2005) implementation in the
Western Pacific
Region. IHR event communications includes public health event
reporting, notification,
verification, information-sharing and risk assessment. It may also
involve official
communications required for the determination of a Public Health
Emergency of
International Concern (PHEIC) and the associated emergency response
under IHR
(2005).
Simulation exercises have been an important component of monitoring
and evaluation
(M&E) of APSED III and IHR (2005). The guiding principles and
mechanisms of M&E
developed for APSED III have contributed to the development of a
global post-2016 IHR
Monitoring and Evaluation Framework comprising four components:
annual reporting;
after-action review; simulation exercises; and joint external
evaluation (JEE). Experience
has shown that such simulation exercises are a useful way to
practice and test key IHR
capacities during peace time, before the actual public health
events and emergencies to
occur.
To strengthen and maintain the functions of National IHR Focal
Points, regular yearly
IHR communication exercises known as ‘IHR Exercise Crystal’ have
been conducted
almost every year since 2008. The exception was in 2009, when
resources were instead
directed to a real life event – H1N1. This event (and subsequent
events, such as H7N9)
highlighted the key role of NFPs and the importance of IHR
communication in
contributing to risk assessment and situation monitoring,
regionally and globally.
In addition to the countries of our region, we are also inviting
territories and areas to
participate in this exercise. Their role differs from that of the
official NFPs, but these
participants are expected to follow the already established lines
of communication for
public health events.
The "IHR Exercise Crystal 2017" will be conducted from 5 to 6
December 2017. It is an IHR communication and assessment
exercise involving NFPs and the WHO IHR Contact Point.
Relevant WHO country office staff will support participants
as
appropriate. The exercise will last for 5 hours on one day
for
each participating Member State, territory or area.
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Objectives
The objectives of the IHR Exercise Crystal are:
1. to validate the accessibility of the National IHR Focal Points
and WHO IHR
Contact Point using registered contact details;
2. to practise and test National IHR Focal Point's assessment of
public health
events using the decision instrument contained in Annex 2 of IHR
(2005);
3. to practise and test National IHR Focal Point's understanding
and use of IHR
principles and obligations;
4. to improve the understanding and familiarity of staff across
Member States and
WHO with the National IHR Focal Point system; and
5. to test the videoconferencing capability of the Emergency
Operations Centre
(EOC) in the WHO Regional Office for the Western Pacific and
National IHR
Focal Points in some selected countries.
Scope and type of exercise
For the 2017 exercise, we will continue to focus on practicing and
testing participants’
awareness and use of IHR principles and assessment of public health
events. The
exercise will continue the theme of past exercises by aiming to
test the accessibility of
National IHR Focal Points and participants from territories and
areas to facilitate
communication and collaboration during an emergency event.
The exercise will be a functional test of emergency systems and
participants will be
required to undertake simulated emergency functions that would
reflect their role in a
real-life developing situation.
The scenario involves an unknown emerging illness and its potential
consequences. The
exercise is designed to test decision-making during the simulated
event and methods of
communicating these decisions. Testing will include the use of
appropriate
communication systems as well as the use of the IHR event
information site (EIS) online
portal. The simulation will consist of a number of problem
statements (injects) that
participants will work through within their own country
context.
Please recognise that this exercise will use a simulated,
artificial scenario that may not
reflect a real-world situation, particularly with respect to
elapsed time, place names and
people. Participants should accept these artificialities. Please do
not be overly concerned
by complexities or details associated with the scenario itself. The
objective is to work
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[email protected]
with the scenario to facilitate your actions, rather than to
challenge it or seek to resolve
every last possible detail.
Remember that this is a simulation exercise. There are no right or
wrong answers and
no individual performance is being tested. The aim of any
simulation exercise is to help
institutions learn by identifying strengths and shortcomings in a
safe environment and
thus help to prepare for a real emergency situation.
Some specific instructions will be issued during the exercise.
However, do not wait to be
prompted first in order to take action. As you receive each inject
containing new
information, consider what you would do if this was a real-life
event and who you would
contact, in line with IHR (2005) and your own national policies and
procedures.
The exercise will be conducted over 5 hours. The first group,
mainly Pacific Island
countries and territories, will take part on 5 December 2017
(Tuesday). A second group,
mainly Asian countries, will participate on 6 December 2017
(Wednesday). Please see
Annex D below for the local time at which the exercise will take
place for each country
and territory.
How the exercise will be conducted
All participants will join the exercise from their normal office
(no international travel
required). The primary means of communication will be email, with
telephone used as a
means of checking communication and troubleshooting. Participants
will be contacted
by email prior to the exercise to confirm contact details. In
addition, the capability of
videoconference will also be tested with selected countries at the
end of the exercise.
This year, some injects will contain short video clips. These
videos are intended to add
some extra “colour” to the scenario. However, to ensure that those
countries and areas
facing challenges with internet connectivity can fully participate,
the emails themselves
will contain all of the necessary information to play in the
exercise.
Participants are expected to act and communicate quickly,
facilitating information flow
within the exercise time period, as they would do in a real world
setting. Participants can
expect to have between 30 and 45 minutes to address each inject.
However, timings
may vary based on the complexity of the situation or the expected
response.
The exercise will be hosted by the Exercise Controller who
will
regulate the pace of the exercise by managing the sequence
of events, including setting the scenario and injects and
monitoring the progress of the exercise. Assisting the
controller will be a facilitator who will assist
communication
between NFPs and WHO and at least one evaluator who
will observe and evaluate the process and outcomes of the exercise.
All of these people
are WHO staff and all information will be held in confidence.
Detail contained in the final
report will be anonymized to ensure confidentiality. Country-,
territory- or area-specific
feedback will only be communicated with the party concerned unless
prior approval is
granted.
The exercise will take 5 hours in real time. This period will be
used to simulate a time
scale of 12 weeks. Simulated times and dates will be communicated
in the email injects
so please read these carefully.
Time for problem-solving and action-taking will be limited to the
time allotted to each
inject. No extra time will be available and new injects may arrive
before participants
have completed the previous task. Do not attempt to produce overly
complicated
reports, as these are not expected within the time frame.
All participants are required to record their actions taken during
the exercise. We
suggest participants to record all actions taken using your local
log, and at the same
time record them at online action log sheet
(https://extranet.who.int/dataform/573774?lang=en), including
actions taken to
communicate with other relevant departments/agencies/ individuals
(if required based
on your communication protocol/procedures) and the results of any
assessment made
using the IHR decision instrument. Online action log sheet will
allow the Exercise
Management Team to monitor the responses of the participants. For
those countries,
territories or areas facing difficulties with internet
connectivity, please record your action
using the action log sheet (Annex B), and inform the controller
(
[email protected])
that the action has taken place. For those not using the online
action log sheet, please
submit your completed action log sheet at the end of exercise to
the controller
(
[email protected]).
At the end of the exercise, WHO will host a videoconference to
review the exercise
(“hotwash”) using Zoom (https://wpro-who.zoom.us/j/6835035263) (see
Annex E for a
guide on how to use Zoom). In case you face difficulties connecting
via Zoom, as a
backup, the WHO Regional Office for the Western Pacific will
telephone participants to
bridge them to the videoconference (audio only).
Who to contact during the exercise
For the purpose of the exercise, the public health unit (or
equivalent) in your own
country will be simulated. As this is a simulation exercise, we do
not expect each country
to contact its own public health department. The simulated public
health unit will be
staffed by “Dr Sabine Manx”. Dr Manx can be contacted by email
at
[email protected]. Likewise, the simulated Ministry of
Agriculture and Animal
Health (or equivalent) of your country will be staffed by Dr Paul
Leopard, who can be
participating, please pretend that
NFP (
[email protected])
Management Authority of your country can also be reached at
[email protected] (see Annex A for the list of simulation
contacts).
All communications with the WHO IHR Contact Point will use
the
same email account that can be used during a real-life public
health event:
[email protected]. However, please indicate
clearly that the communication is part of the exercise (i.e.
stating EXERCISE-EXERCISE-EXERCISE at the top of the
message). If a real incident occurs during the simulation,
ensure that all communications contain the subject line
ATTENTION-ATTENTION, THIS IS NOT A DRILL. This will
ensure that real messages to IHR are identified and given
priority.
Please note that there is no simulator arranged for other,
non-participating or non-
playing agencies. DO NOT copy any person or agency outside the
simulation as this can
lead to confusion or concern. If players want to communicate with
another relevant
agency (e.g. their civil aviation authority, or NFPs in other
countries) they should simply
record this pretended 'action' using the online action log sheet
(or the paper version
included in Annex B) and notify the controller via email
(
[email protected]) that the action has taken
place. This should be done with NO real
involvement or communication with the agency.
Internal discussions within the office of the
NFPs are encouraged to facilitate exercise
play, but always remember to be clear that
the discussions pertain to an exercise, not a
real event.
For urgent problems experienced during the
exercise, contact Exercise Control via telephone
(+63 2 528 9049). Other issues can be sent via email
(
[email protected]). Please also record any
encountered problems using the online problem log sheet.
If a participant needs to withdraw from the simulation at any time,
please immediately
send a message to
[email protected].
1. Always start and end communication with "EXERCISE –
EXERCISE - EXERCISE" or “THIS IS AN EXERCISE MESSAGE"
2. Include your country name in the subject line of every
email
communication to facilitate tracking of responses
3. Copy every email communication to
[email protected]
4. Please do not fight the scenario
5. Record all of your activities using your local log, and at
the
same time record them at online action log sheet
(https://extranet.who.int/dataform/573774?lang=en)
6. If online action log sheet is not accessible, please use the
off-line action log
sheet (Annex B), and always notify the controller via email if you
have taken an
action (
[email protected]).
7. If you encounter any problems during the exercise, please record
them on the
problem log sheet (Annex C)
8. Participate in a review “hot wash” via videoconference or
teleconference to
debrief at the end of the exercise
(https://wpro-who.zoom.us/j/6835035263)
9. Fill out and submit the evaluation form after the exercise
online or using the
paper form (https://extranet.who.int/dataform/148757?lang=en)
10. Enjoy the exercise !
Participants will be asked to complete an online evaluation
form
(https://extranet.who.int/dataform/148757?lang=en) to help the
exercise management
team collect comments and suggestions. A paper copy of the
evaluation form is also
available (Annex F), in case you run into any difficulties with the
online form. A short
report will be developed by WHO and provided to participants. A
short report will be
developed by WHO and provided to participants.
Annexes
Annex D Exercise schedule
Annex E Zoom participant guide
Annex F Exercise evaluation form
NOTE: If possible, participants should use the online versions of
the action log and the
evaluation form. However, we have included offline versions as
annexes in case you run
into technical difficulties and cannot use the online forms.
action! Send your
Controller
Every communication should always be copied to Exercise Controller
at:
[email protected]
Health
[email protected]
[email protected]
[email protected]
NOTE: Do not use any email addresses other than those listed as
communication to
other addresses will not be answered and may cause confusion or
concern to outside
individuals.
https://extranet.who.int/dataform/573774?lang=en
https://extranet.who.int/dataform/148757?lang=en
Getting help:
(Annex C)
528 9045)
22
Annex B: Action log sheet – IHR Exercise Crystal 2017 NOTE: Please
use the online action log form to submit actions. However, this
form is a back-up option in case you run into technical
difficulties.
Name __________________________ Position _______________________
Location (country/territory/area) ____________________ Page __ of
___
Time/Date
Activity
Please send the completed sheet via e-mail to
[email protected]
immediately after the exercise (by 8 December 2017 latest)
Annex C: Problem log sheet – IHR Exercise Crystal 2017 Exercise
Assignment: (circle) Participant, Controller, Simulator, Evaluator,
Director, Observer
Time Message
no. (if
Please send the completed sheet via e-mail to
[email protected]
immediately after the
exercise (by 8 Dec, 2017 latest)
1 American Samoa (4 Dec) 12:00 – 17:00 07:00 – 12:00
2 Cook Islands (4 Dec) 13:00 – 18:00 07:00 – 12:00
3 Fiji 12:00 – 17:00 07:00 – 12:00
4 French Polynesia (4 Dec) 13:00 – 18:00 07:00 – 12:00
5 Guam 09:00 – 14:00 07:00 – 12:00
6 Kiribati 11:00 – 16:00 07:00 – 12:00
7 Marshall Islands 11:00 – 16:00 07:00 – 12:00
8 Micronesia, Federated States 10:00 – 15:00 07:00 – 12:00
9 Nauru 11:00 – 16:00 07:00 – 12:00
10 New Caledonia 10:00 – 15:00 07:00 – 12:00
11 New Zealand 12:00 – 17:00 07:00 – 12:00
12 Northern Mariana Islands 09:00 – 14:00 07:00 – 12:00
13 Niue (4 Dec) 12:00 – 17:00 07:00 – 12:00
14 Papua New Guinea 09:00 – 14:00 07:00 – 12:00
15 Palau 08:00 – 13:00 07:00 – 12:00
16 Samoa 13:00 – 18:00 07:00 – 12:00
17 Solomon Islands 10:00 – 15:00 07:00 – 12:00
18 Tokelau 12:00 – 17:00 07:00 – 12:00
19 Tonga 12:00 – 18:00 07:00 – 12:00
20 Tuvalu 11:00 – 16:00 07:00 – 12:00
21 Vanuatu 10:00 – 15:00 07:00 – 12:00
DAY 2: 6 December 2017 (Wednesday)
Participating Country/Territory/Area Local time Manila Time
1 Australia 12:00 – 17:00 09:00 – 14:00
2 Brunei Darussalam 09:00 – 14:00 09:00 – 14:00
3 Cambodia 08:00 – 13:00 09:00 – 14:00
4 China 09:00 – 14:00 09:00 – 14:00
5 Hong Kong SAR (China) 09:00 – 14:00 09:00 – 14:00
6 Japan 10:00 – 15:00 09:00 – 14:00
7 Lao People’s Democratic Republic 08:00 – 13:00 09:00 –
14:00
8 Macao SAR (China) 09:00 – 14:00 09:00 – 14:00
9 Malaysia 09:00 – 14:00 09:00 – 14:00
10 Mongolia 09:00 – 14:00 09:00 – 14:00
11 Philippines 09:00 – 14:00 09:00 – 14:00
12 Republic of Korea 10:00 – 15:00 09:00 – 14:00
13 Singapore 09:00 – 14:00 09:00 – 14:00
14 Viet Nam 08:00 – 13:00 09:00 – 14:00
25
What You Need To Get Started
An internet-connected computer, laptop, or device with camera
function
How to Launch Zoom
Please click following Zoom link both for testing and for
videoconference as part of
exercise: https://wpro-who.zoom.us/j/6835035263
After clicking the link, a dialog box may appear asking to launch
Zoom and then to install
an application plugin. If prompted on-screen, please select “Run”
to allow the installation of
a small, but necessary, plugin package.
For testing and videoconference
If needed, participants can connect anytime for their testing at
above link. We suggest
installing the plugin before the exercise starts.
On the day of the exercise, at the end of IHR Crystal exercise, we
will arrange a
videoconference for review (also called a “hot wash”), for which
you will be able to
participate by using the link above.
In case you face difficulties in connecting with Zoom, as a backup,
the WHO Regional Office
for the Western Pacific will telephone participants to bridge them
to the videoconference
(audio only).
When you are not speaking, we suggest you to mute your microphone
(please see below).
Audio Mute and Unmute
During a session you might be asked to mute your microphone until
you have a
question or comment. This helps to minimize audio feedback. Mute
your audio by
clicking on the microphone icon located in the lower left-hand
corner of the menu bar.
Audio is not muted Audio is muted
27
Annex F: Evaluation Form – IHR Exercise Crystal 2017 NOTE: Please
use the online evaluation form to submit your comments and
suggestions. However, this form is a back-up option in case you run
into technical
difficulties.
______________________________________________________________________
Please take a few minutes to fill out this form. Your feedback and
suggestions will help us
prepare and improve future exercises. Thank you for your
cooperation!
Exercise Objectives:
Validate the accessibility of the National IHR Focal Points and WHO
IHR Contact Point
using registered contact details
Practice and test National IHR Focal Point's assessment of public
health events using the
decision instrument contained in Annex 2 of IHR (2005)
Practice and test National IHR Focal Point's understanding and use
of IHR principles and
obligations
Improve the understanding and familiarity of staff across Member
States and WHO with
the National IHR Focal Point system
Test the video teleconferencing capability of the Emergency
Operations Centre (EOC) in
the WHO Regional Office for the Western Pacific and National IHR
Focal Points in some
selected countries.
1. Did the exercise meet your expectations (i.e. did it do what you
were led to believe in your
invitation)?
(1) Yes, fully (2) Yes, partially (3) No, not at all
If you answered (2) or (3), please briefly explain why:
________________________________
2. Did the exercise achieve the stated objectives?
(1) Yes, fully (2) Yes, partially (3) No, no at all
If you answered (2) or (3), please briefly explain why:
________________________________
3. What do you think about the scope of the exercise?
(1) Suitable (2) Too narrow (3) Too broad
If you answered (2) or (3), please briefly explain
why:________________________________
4. Did you find the exercise helpful and/or useful in facilitating
the event-related
communications?
If you answered (2), please briefly explain
why:_____________________________________
5. What are two useful things that you have learned/observed from
the exercise?
(1)
______________________________________________________________________
(2)
______________________________________________________________________
6. What are two priorities that you would suggest for improvement
in the future?
(1)
______________________________________________________________________
(2)
______________________________________________________________________
Please send the completed form via e-mail to
[email protected]
immediately after
the exercise (by 8 December 2017 latest)
30
YC-1
VIA Email
FROM
[email protected]
Responsible For Information
TO All Participants
COPY (info)
[email protected]
SUBJECT Exercise Message: Initial Message – Outbreak of new disease
in cats
Inject time Start of exercise
Expected
Actions
Respond to call from WPRO if required
Comments This incident is very unusual and the national veterinary
service would like
to know more details. As the disease is infecting household pets as
well as
wild cats there is concern that this could be spreading more
widely
through the general feline population. There are anecdotal reports
of people catching a form of influenza from
infected cats but these have not been confirmed.
31
YC-1
@paula23819
Poor Biggles the cat is not in a good way. Hope the vet can help
#catflu #feelingpoorly
Social Media Post
@ataki9873
Feeling awful. Lying in bed with my cat who has tears on his face
for me. Hope he is not sick also.
#catflu
@lia29875320
My cat died today. Took him to the vet after he started bleeding
from his nose. Too late #catflu
THIS IS AN EXERCISE MESSAGE
Date: Day 0
Location: Your country
Social Media Posts
Meow Instant messaging
FELIX This how my cat looks this morning. He’s been poorly a couple
of days but I’m taking him to the vet today as there is BLOOD on
his nose and mouth. I don’t want to go out though cause I’m feeling
sick myself, but poor puss.
Like – Comment - Share
Simulation – Simulation – Simulation
32
YC-1
Rue Mores – Staff reporter,
Mystery of the cat deaths in Nearby Province
Province City, Nearby Province: Local people are mystified by a
disease sweeping through our feline
friends. Cats in a few villages in Nearby Province seem to be
catching a nasty form of cat flu. Cat flu is
usually treatable and vaccine preventable but nothing seems to be
helping the cats in this case.
Symptoms include streaming eyes and blood from the nose and mouth.
The cats die shortly after
symptoms appear but some owners report that the cats seem unusually
inactive for a few weeks
before any obvious signs.
Social media is alive with reports of sick cats with many owners in
the area posting comments about
the health of their pets.
Our reporters have discovered that people have been finding dead
cats around the towns for a few
weeks now and while most people put this down to cats being hit by
traffic or otherwise meeting
accidental deaths, the numbers are unusual.
Our reporter investigating the incident found at least 5 dead cats
and collected them to take to a local
vet for investigation and we await the results with interest. There
have been rumours that a nearby
chemical plant has been the cause of the deaths, but the company
has denied that there is a problem
and has pointed out that it appears that only cats are
effected.
Simulation – Simulation – Simulation
33
YC-1
Memo:
From: Chief Veterinary Officer, Ministry of Agriculture and Animal
Health,
To: Your Country Ministry of Health, Public Health,
CC: IHR Focal Point
Subject: Routine event based surveillance through Social Media.
Possible alert.
Routine event based surveillance through Social Media and local
press has detected a number of
messages discussing an illness in cats. Users of social media are
posting comments and messages
stating that their cats have become ill with a strange disease.
Most of the pictures posted show what
appears to be a severe form of cat flu and owners are describing
this as such.
Owners are reporting that the cats are not responding to treatment
and in many cases, are reporting
that their cats have died or have been put down. There have also
been occasional messages stating
that people have seen dead or dying cats in the area
Local veterinary practices in the area have requested advice on
treatment and have confirmed that
regular treatments do not appear effective. They have stated that
the illness falls outside a routine
cycle of illness in cats. Infected cats appear to bleed from the
nose and mouth, exhibit watery eyes and
very quickly die from the disease, probably from organ failure.
Fatality rate in cats is at least 80% of
cases.
All of the cases reported both by veterinary professionals and
users of social media indicate that the
disease seems to be concentrated in one area of Nearby Province
(the province 122 km from Your
Capital). The people posting appear to live in relatively close
proximity to each other. This has been
verified by vet reports as well as GPS metadata on photographs and
IP address spread.
One vet stated that after handling one of the infected cats he came
down with a type of flu and felt
quite unwell for a few days. He also mentioned that his daughter
also had a high fever but he was
unsure if it is the same thing. This was also reflected in social
medial posts which also mentioned that
some of the owners of the cats are also feeling unwell with flu
like symptoms. These have been
described by the owners as ‘mild’ with posts stating that the
owners have caught ‘sympathy flu’ with
their cats. There may be a link and this should be
investigated.
Actions
Please acknowledge the receipt of this memo
The WHO team may also reach out to check our communication via
phone call.
Simulation – Simulation – Simulation
34
YC-2.1
VIA Email
FROM
[email protected]
TO IHR NFP
Forward IHR DO
COPY (info)
[email protected]
Inject time
Expected
Actions
Log in to IHR event information site (EIS) and confirm login Check
the Global Early Warning System for health threats and
emerging risks at the human–animal–ecosystems interface (GLEWS+)
and World Animal Health Information Database (WAHIS)
Provide contact details for animal health teams
Comments Confirm with participants that EIS is accessible
35
YC-2.1
Report from Veterinary Assessment Team - Memo
From: Dr Paul Leopard, Chief Veterinary Office, Ministry of
Agriculture and Animal Health (or YOUR
COUNTRY equivalent)
Date: +2 weeks
Subject: URGENT, Unusual findings – Investigation into illness in
cats in Nearby Province
Assessment team report:
This morning our team returned from Nearby Province after
conducting an investigation into
unexplained death in cats reported in Nearby Province City. While
this investigation was concentrating
on animal health, the team wished to emphasise the unusual nature
of the illness and an illness in
humans that appears to be related.
Preliminary results of the animal health investigation:
1. This is an unknown novel illness in the feline population. The
initial source appears to be the wild cat population and the
disease has moved into domestic cats possibly through contact
transmission. The actual method of transmission in cats is unknown
and it appears highly contagious
2. The illness develops rapidly in cats with death most commonly
occurring within a week. 3. Most cases appear to result in death
through multiple organ failure. There appears to be a
haemorrhagic element to the disease that results in bleeding, most
obviously through the nose and mouth
4. Deaths in cats occurs in almost all cases once the cat shows
signs of bleeding 5. Specimens from infected animals have been
taken for further investigation
During the investigation, the team cases of illness in those humans
who kept infected cats as pets or
worked with infected cats (particularly veterinary workers). In
many cases the owners of infected cats
stated that they had a ‘cold or flu’ when interviewed by the
assessment team. In at least one case, an
elderly woman developed a very severe illness that doctors in the
hospital in Nearby Province City are
attempting to treat.
Recommendation:
The Department of Agriculture and Animal Health would like to
highlight what may be a connection
between the unexpected illness in cats and the subsequent
development of symptoms in humans. We
are sharing this information should you wish to investigate this
further. In some cases, people reporting
sick were relatives of cat owners but did not own cats
themselves.
Dr Paul Leopard
Simulation – Simulation – Simulation
36
YC-2.1
Memo
To: IHR National Focal Point
Subject: Joint assessment, animal health
Date: + 2 weeks
Refer to the attached statement from the veterinary officer at the
Department of Agriculture
and Animal Health. His report is suggesting that there may be a
link between the recent illness
in cats and reports of illness in people who have been in close
contact with cats.
I am recommending the following:
1. A joint rapid response team (animal and human) be sent to Nearby
Province to investigate due to the unusual nature of the illness if
they have not already done so,
2. Specimens be taken from infected animals and suspected human
cases for analysis. I would like the following to be
undertaken:
1. Please supply the contact details for our assessment counterpart
at the Ministry of Agriculture and Animal Health or the most
appropriate department to join the assessment team. I require a
name, address, contact number and email in order to provide the
correct invitation for joining the team,
2. Please log in and search the event information site (EIS) and
report if you find any events that may appear similar, or not. I
need to know if this is a known illness or one that is emerging.
Please also check the Joint FAO–OIE–WHO Global Early Warning System
for health threats and emerging risks at the
human–animal–ecosystems interface (GLEWS+) and World Animal Health
Information Database (WAHIS). If you cannot login to EIS, please
also inform me immediately.
Thank you,
37
YC-2.3
Rue Mores – Staff reporter,
‘Cat Flu’ Spreads.
Today the Chief Veterinary Officer described the Cat Flu illness as
‘serious’ and recommended
that the government undertake a further investigation of the
matter. He stated that the
illness was not confirmed but that further investigation was
warranted.
She told News First that the disease appeared different to other
forms of illness usually seen
in cats and that this should be investigated further. She stated,
‘It is important that the
relevant authorities have a better understanding of this new
illness in cats. As a result, I am
recommending that the government explores the situation thoroughly.
At this time, we are
not calling it ‘Cat Flu’ as it does not present in the same way as
other illnesses in cats.’
In related news, several children at a primary school near to where
the initial cat flu outbreak
occurred have become ill. It appears that the children had been
feeding stray cats that come
to the school. Mr Nebelung, the Head teacher at the Selkirk Rex
Primary school stated that he
was worried that the illness in the children may be related as he
had heard reports of people
being able to contract the disease from cats. Local health
authorities are more cautious,
stating that flu is common in children, particularly at this time
of year, however the symptoms
of some of the children are more severe than the usual seasonal flu
and that they are
monitoring the situation. The cases have been reported to the
regional health authorities.
© 2017 News First.
Simulation – Simulation – Simulation
38
YC-2.3
Rue Mores – Staff reporter,
Keep your cat close.
Cats, our beloved feline friends face a new threat today.
Veterinary professionals are baffled by a new
strain of what appears to be cat flu that has appeared near the
capital. The new strain of flu is not
responding to regular treatment and the animals are dying at an
alarming rate.
How do I know if my cat has the new disease?
Cats may initially be more sleepy or lethargic than usual. Once
symptoms become obvious however,
the disease progresses very rapidly. Red watery eyes seem commonly
be the first symptom. Within 24
hours owners notice the cat begins bleeding from the nose and
mouth. Some owners describe this as a
sort of red foam. Death usually occurs within a couple of days of
initial symptoms. Some cats have
been known to recover but this seems rare.
How can I protect my cat?
It appears that regular vaccination of cats with standard feline
vaccines is ineffective in this case.
Standard treatment cat diseases also appear to have limited
success. The best course of action is to
keep your cat indoors and do not allow it out in case it comes into
contact with other cats or strays. At
this stage, we do not know where the illness has originated.
Can I get sick from my cat?
At the moment, we don’t know. Some owners have reported getting
fever, flu-like symptoms or
feeling generally unwell after their cats became sick. One elderly
lady was admitted to hospital with
severe respiratory problems and one of her cats was later found
dead in her home. This may or may
not be unrelated.
© 2017 News First.
Simulation – Simulation – Simulation
39
YC-3.1
TO IHR
Inject time + 3-4 weeks
Expected Actions Complete an initial risk assessment and submit to
the Director of public health unit
Comments 1 hour completion time
40
YC-3.1
Memo
To: National IHR Focal Point
Date: +3 weeks
Subject: Report of severe illness and possible human to human
transmission
Severe illness leading to death
The Public Health Unit has been informed that a 28-year-old female
was admitted to hospital with the
following symptoms:
1. High Fever, persistent and above 38°C 2. Conjunctivitis 3.
Muscle Pain 4. Shortness of breath
As the disease progressed the following was also noticed:
1. Jaundice 2. Nausea and Vomiting 3. Petechial/purpuric rash
The patient continued to deteriorate. She was admitted to the
intensive care unit and placed on
mechanical ventilation on day two after admission. On day four the
patient died of suspected multi-
organ failure.
Since the admission of the primary case, 30 other cases have been
referred with similar symptoms,
most typically persistent high fever and conjunctivitis, as well as
in some cases vomiting and rash.
These symptoms are consistent with other cases of the recent
illness in people associated with
infected cats.
Of concern in this case was that the victim had no recent contact
with cats and had taken active steps
to keep away from the animals as she has had a severe allergy to
cats. This victim was the
granddaughter of the 76-year-old female who was admitted with
severe symptoms three weeks ago
and who remains in intensive care. The granddaughter was regularly
visiting her grandmother and
frequently in close contact.
Possible cluster of cases associated with the Selkirk Rex Primary
school.
Public health authorities are conducting further investigations
into cases connected with the Selkirk
Rex Primary School. Since the initial seven cases there have been a
further 12 cases of children at the
school with fever and conjunctivitis. In the past 24 hours two of
these cases have been admitted to
hospital and are showing very severe symptoms, including;
Simulation – Simulation – Simulation
41
YC-3.1
1. High fever 2. Jaundice 3. Purpuric rash
These further cases have emerged after the removal of cats from the
school and are possibly the result
of human to human contact with other sick children.
Contact tracing has revealed that 6 of these children attended a
multi school sports tournament.
Enquiries have revealed that a further 8 children from three other
schools have taken time away from
school due to illness following the sports tournament.
The Ministry of Education should be able to provide details.
Actions to minimise spread should be taken
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42
YC-3.2
TO IHR
Inject time + 3-4 weeks
Expected Actions Complete an initial risk assessment and submit to
the Director of public health unit
Comments 1 hour completion time
43
YC-3.2
From: Dr Sabine Manx, Public Health Unit
To: National IHR Focal Point
Date: +4 weeks
Dear IHR National Focal Point,
I am attaching the report from the rapid response team (RRT).
Please assess the public health risk
of this event, based on the attached report, and using multiple
sources of information you may
have.
Please complete a risk assessment given the material received and
forward this to me within
the next hour.
44
YC-3.2
Initial Report
Review of emergency department presentations:
Review of medical records indicates that 46 patients presenting
with fever in the last month also had conjunctivitis
The number of gastro-intestinal illness presentations (vomiting
and/or diarrhoea) were slightly above average this month (30
presentations versus average of 22 per month)
Influenza-like illness presentations are above average this month
(24 presentations versus average of 10 per month) Review of
hospital admissions:
Hospital admissions this month (N=120) are substantially higher
than the average over the past 12 months (91 per month, range
70-105).
Admissions to critical care beds have also increased in the last
month (N=25), compared with an average of 15 per month. Sixteen of
the 25 critical care admissions this month were admitted with a
febrile illness. Four of them died. Key findings:
Investigation of 3 cases of illness by the rapid response team
(RRT):
Case # Details
Case 1 Age 5 years, female
Contact with pet cat which died 5 days prior to onset Developed
fever and severe conjunctivitis 6 weeks ago. Condition
deteriorated
and was admitted to the hospital on 1 November. On presentation was
hypotensive, tachycardic and observed to have petechial rash on
lower limbs. Supportive treatment provided and condition improved
from day 6 of admission.
Case 2 Age 60 years, female
Contact with pet cat which died one week prior to case onset
Presented to community health centre 4 weeks ago with fever,
headache and
conjunctivitis. Given anti-pyretic and anti-microbial eye drops.
Full recovery 1 week after onset.
Case 3 Age 34 years, male
Local veterinarian
Found unresponsive at home. Severe shock on arrival in emergency
department on 2 weeks ago, unable to be resuscitated –
deceased.
Relatives of the case noted that he was feeling unwell with fever,
headache and sore eyes the day prior.
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45
YC-3.2
The RRT discussed the situation with hospital staff, who commented
on the unusually high number of
patients presenting with conjunctivitis as well as noting several
young healthy patients who have
recently been admitted with haemorrhagic signs and shock on a
background of pyrexia of unknown
origin.
The RRT was able to interview a sample of 10 patients who had
presented to hospital with fever and
conjunctivitis during the past 6 weeks:
Of 10 interviewed cases: 6 males and 4 females. Age range 16 years
– 65 years A range of other symptoms were reported by cases,
including: headache, retro-orbital pain, arthralgia,
nausea and diarrhoea. Seven of the cases are cat owners, 2 of which
had cats that had recently died. One case had contact
with a friend’s cat prior to onset. Two cases reported no contact
with cats, one of which reported contact with a friend who had
had
similar symptoms about a week prior. Of note, the other case with
no cat contact was a nurse who was involved in the resuscitation of
a veterinarian who had been brought to the hospital in cardiac
arrest.
Specimens were obtained from seven of the ten cases interviewed and
were sent to national reference laboratory.
The population appears to seek health care late as early symptoms
are mild in most people.
Perception Issues:
There is an increasing level of interest in the press
There are reports that people are hiding sick cats for fear of them
being put down if found to be unwell.
Strong comments on social media, often displaying incorrect or
factually dangerous information
Recommended actions:
Elevate the level of emergency operations centre (or equivalent in
your country), and activate incident management system
Establish case definition and interim guidance for clinical
management Follow-up results of laboratory testing
Strengthen public health interventions, including risk
communication, infection prevention and control, and contract
tracing.
Ensure that the public receive accurate and objective
information
END of REPORT
Simulation – Simulation – Simulation
46
VIA Email
FROM
[email protected]
TO IHR
Inject time +6 weeks
Expected Actions Assess if the situation meet criteria for WHO
notification as per
IHR(2005) Annex 2
Draft and send EIS posting
Comments +6 weeks
47
Rue Mores – Staff reporter,
12 people dead, 5 of these children and over 50
critically ill as Cat Flu Spreads.
What started out as a mild case of flu in cat owners has become a
health threat to the nation.
Today the Ministry of Health is racing to contain the outbreak of
the disease known locally as
Cat Flu but described by health authorities as Acute Complex Feline
Syndrome (ACFS). ACFS
has already claimed the lives of 12 people, almost half of these
children and has now spread
to the nation’s capital.
As of today, there have been over 50 confirmed serious cases. There
are undoubtedly more
cases in the general population, people staying at home with what
they believe is the flu.
What do we know so far?
ACFS appears to be highly infectious but experts are still divided
as to how the disease
spreads. Some believe that the transmission is similar to influenza
and is spread by coughing
and sneezing while others believe it is through close physical
contact with an infected person.
Regardless of how it is spread, health experts are recommending
that anyone who suspects
that they have the illness should not go to health care facilities
to prevent further
transmission, and instead make phone call to a local public health
center.
Dr Sabine Manx of the Public Health Unit told News First that
people should stay at home.
"We are very concerned about the continued spread of ACFS. It is
clear that the disease
spreads easily between people but we are still unsure of the exact
mechanism. Until we
understand more about the disease we strongly recommend that people
stay at home unless
they become very ill. In most cases people will suffer mild
symptoms, including fever and
conjunctivitis and these are best treated with rest and plenty of
water. If people do become
very ill, they should call ahead to their local public health
center, so that staff can arrange
appropriate medical assessment.. At present the ministry of health
is establishing dedicated
wards at local health facilities to try to isolate victims of this
illness. We are also actively
tracing the contacts and asking them to remain quarantined at
home.”
Mr Manx stated that the ministry was doing all it to understand the
disease better in order to
limit its spread.
© 2017 News First.
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48
YOUR COUNTRY REFERENCE LABORATORY
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49
50
From: Dr Sabine Manx, Public Health Unit
To: National IHR Focal Point
Date: +6 weeks
Subject: Case Management and Investigation
Dear IHR National Focal Point,
Please take note of the information received from our ongoing
investigation into cases of Acute
Complex Feline Syndrome (ACFS).
Please undertake the following appropriate action:
1. Please assess the current situation against Annex 2 of the
International Health Regulations (IHR)(2005) and advise if the
current situation warrants notification to WHO, and please let me
(
[email protected]) know your judgement.
2. Should this situation warrant notifying to WHO, please brief me
(
[email protected]) on the national procedure to obtain
approval for notifying WHO.
3. Please also prepare a posting for the event information site
(EIS) and email it to the WHO IHR contact point for uploading into
the system.
(FOR THE PURPOSES OF THE EXERCISE DO NOT UPLOAD ANY INFORMATION
DIRECTLY TO THE EIS
SYSTEM).
51
YC-5.1
VIA Email
FROM
[email protected]
TO IHR NFP WHO IHR DO
COPY (info)
[email protected]
Inject time (Manila) + 8 weeks
Expected Actions Provide contact point for national disaster
management structure
52
YC-5.1
Rue Mores – Staff reporter,
Death toll in YOUR COUNTRY rises as the disease arrives in the
nation's capital
122 people dead, and at least 550 critically ill as ACFS takes
hold.
Acute Complex Feline Syndrome (CFS) is now spreading across the
country. For the first time ACFS has
been detected in the capital of YOUR COUNTRY alarming health
authorities who have been struggling
to contain the outbreak.
A spokesperson for the Ministry of Health stated, “We are concerned
about the spread of ACFS as it
now seems to have established itself in the human population and
appears to be spreading easily.
People who develop only mild symptoms of the illness can still pass
the infection on to others. We ask
that any person who feels unwell with fever and conjunctivitis to
stay at home unless they are in real
need of medical attention.
The majority of cases recover without treatment. However,
approximately 10% of cases develop a
serious form of the disease. This outbreak is impacting health
facilities and it is therefore important
that people take measures to prevent the further spread of
infection.”
© 2017 News First.
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53
YC-5.1
THIS IS AN EXERCISE MESSAGE
From: National Disaster Management Authority or Agency (NDMA) of
YOUR COUNTRY
To: National IHR Focal Point
Date: +8 Weeks
Dear National IHR Focal Point
The National Disaster Management Authority or Agency (NDMA) has
been monitoring the
situation and is on standby in case support services are required.
The NDMA can provide the
following:
1. Tankered water services, 2. Food supplies and emergency food
kitchens 3. Tented accommodation to support staff on site and/or
patient overspill 4. Emergency transportation 5. Blankets and camp
bedding 6. General logistics support
The NDMA has the immediate capacity to deal with approximately 1000
people but this can
be increased if required over time.
NDMA
54
YC-5.2
From: Dr Sabine Schmitz, Public Health Unit
To: National IHR Focal Point
Date: +8 weeks
Subject: Case numbers
Executive Summary:
1. Number of Cases continues to rise with 728 suspected cases, and
550 critically ill 2. Number of new cases reported since yesterday
156 3. Fatalities 122 4. National Disaster Management Agency is on
standby. 5. ACFS is known to spread through direct person to person
contact and through contact with
contaminated objects. 6. The virus remains active on surfaces for
up to 8 hours. Contaminated surfaces should be cleaned with
bleach or exposed to UV radiation (sunlight). General cleaning with
soap is not completely effective but appears to shorten the virus’s
persistence in the wild.
7. Handwashing with soap and water is recommended to prevent
spread. 8. Ambulance services are reduced due to the time required
for disinfection following transport of
suspected cases.
Actions
1. Please send me the contact details for our counterparts at the
National Disaster Management Authority or Agency (NDMA) who could
assist with logistics and support
Dr. Sabine Manx
55
YC-6
VIA Email
FROM
[email protected]
Responsible IHR National Focal Points, IHR contact points,
NFP’s
TO IHR NFP WHO IHR DO
COPY (info)
[email protected]
Inject time + 12 weeks
Expected Actions Provide response to the question on border
closure. Provide response to the question on the point of
entry.
56
YC-6
Rue Mores – Staff reporter,
OTHER COUNTRIES REACT
Acute Complex Feline Syndrome (ACFS) is now spreading across the
globe. For the first time ACFS has
been detected in two countries outside YOUR COUNTRY alarming health
authorities around the globe.
A spokesperson for the World Health Organization stated,
“We are closely monitoring the spread of ACFS as it now seems to
have established itself in the human
population and appears to be spreading easily. In the early stages
the disease appears difficult to detect
and some people who are asymptomatic seem to be able to pass on the
virus. WHO is not
recommending any travel or trade restrictions as we feel that
imposing such restrictions will have little
impact. We recommend that all Member States share what they know
about the virus and take
appropriate steps to limit the spread of the illness”
The Republic of GlobalLand closes its borders
The nearby country of GlobalLand has announced that it will close
its borders to try to prevent the
entry of the disease into the country. A government spokesperson
stated;
“This is a very serious situation and we must do everything
possible to prevent the arrival of this
disease into GlobalLand. Unfortunately, GlobalLand does not have
the resources to enable screening at
its borders or contact tracing for individuals suspected of being
infected. As a result, we will be closing
our borders to all travellers.”
Human rights advocates have expressed concern at the move and they
are worried that GlobalLand is
rounding up recent arrivals, particularly arrivals from YOUR
COUNTRY and placing them in forced
quarantine. The WHO has also expressed concern and has reminded
GlobalLand of goals and their
obligation under IHR.
Cases in other countries
So far there have been 40 cases of suspected ACFS reported in two
NEIGHBOURING COUNTRIES to
YOUR COUNTRY
They have stated that they are working closely with health
officials from YOUR COUNTRY to benefit
from your experience with the illness.
© 2017 News First.
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57
YC-6
National Disaster Management Authority or Agency (NDMA)
[YOUR COUNTRY]
To: Public Health Unit
Date: +12 Weeks
Summary of Activities
1. Assisting with the deployment of 5 tented medical facilities in
locations across the main city to augment existing hospital
capacity
2. Coordinating with the military on the deployment of field
hospitals. Locations are being determined in collaboration with the
Health Department.
3. Activating first response capacity with the NDMA to assist with
triage 4. Providing clean water and sanitation to tented operations
5. Staffing field kitchens 6. Providing emergency patient transfer
and vehicle disinfection 7. Liaising with the police to improve
security at health facilities 8. Providing emergency power and
lighting kits to provide backup power to site 9. Assist with public
health messaging and community engagement
Please also note that following a review of our capacity we are
also available to help with screening at
points of entry and can provide emergency assistance to assist with
the clearing of emergency goods
imported for this crisis
The NDMA stands ready to assist when it can and would welcome
further collaboration.
Joseph Ocicat
Operations, NDMA
TASK
1. GlobalLand closed the border to restrict movement of people and
goods. What action would you consider in such situation?
2. Given this scenario, what measures would you consider at your
point of entry?
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58
YC-6
Final Note to Participants EXERCISE-EXERCISE-EXERCISE Dear Exercise
Crystal participants, The Director-General of the World Health
Organization has declared the outbreak in YOUR COUNTRY a Public
Health Emergency of International Concern: “Based on the
recommendations of the Emergency Committee, I am declaring this
outbreak a Public Health Emergency of International Concern. We are
seeing the spread of the epidemic beyond international borders and
there is a need for an international response. The recommended
control measures such as strict hygiene practices, identification
and isolation of infectious cases and adequate use of personal
protective equipment must be enforced. At this point, the Emergency
Committee is not recommending any travel or trade restrictions.” –
WHO Director-General Watch the video of the DG’s press conference.
This is the end of the exercise. Please be on standby to
participate in a “hot wash” debriefing. Those who are joining via
videoconference, can join here. Our team will call those who are
connecting via teleconference shortly to facilitate your
connection. Regards, Exercise Control
Simulation – Simulation – Simulation
Objectives
1. To validate the functional accessibility of the NFPs and the WHO
IHR Contact Point using registered
contact details;
2. to practice and test NFPs’ assessment of public health events
using the decision-making instrument
contained in Annex 2 of IHR (2005);
and its notification process including IHR event information site
(EIS) posting;
3. to pr