Pandemic Avian Influenza Tabletop Exercise Stakeholder Small Group Roles 2023

Stakeholder Group 1: Local Health Department

The Local Health Department is the agency in charge of the response to all public health emergencies. The stakeholder
small group assigned this role will take a leadership role within the exercise. As you move through this exercise, consider
strategically who you need to communicate within other stakeholder groups in your role you are assigned. This exercise
starts 3 weeks after Avian Influenza is declared a Global Pandemic. Think about your personal experience with the COVID-
19 pandemic as you traverse this exercise. Remember, no vaccine is available at this time. You anticipate its production in
about 6 months. You have information that only the hospital and health departments know. Others need to be made
aware. Think through how to effectively communicate this information who should do the communicating, and to who
needs to be informed first.

Within your stakeholder TBL group, roles should be assigned or chosen:

Health Department Director/Incident Commander(s) (2 people)

One of you is the Director of the Cuyahoga County Board of Health (CCBH), the largest Health Department in the County,
serving about 1 million lives. The other is the Director of Cleveland Department of Public Health (CDPH), serving about
350,000 lives, including those with least access to resources and most vulnerable to serious consequences of the
Pandemic. You are both large and in charge. The Incident Commander is the only position that is always staffed in the
EOC, so the 2 Health Directors must work closely together keep the role staffed and to assure best possible response. You
are the Incident Commanders and primary spokespeople during this crisis. You set incident objectives and priorities and
have overall responsibility for the pandemic response. It is your job to organize all resources and facilitate information
gathering and decision making. The ICS organization has the capability to expand or contract to meet the needs of the
incident. The CCBH Director is married and have 3 teenage children. The CDPH Director is married and has 2 adult
children. You have known for at least a month before it was public information that a public health emergency was a high
probability event. Though you try to alert the community to his likelihood, warnings have tended to be ignored, assuming
it would be just like the COVID Pandemic. Since the pandemic started, you have worked 10-12 hour days, 6-7 days per
week. You were among the first to know when index cases were admitted to both MetroHealth and University Hospitals
Cleveland Medical Center and when the diagnosis of Avian Influenza was diagnosed. You are the first to know that the
Ohio Department of Health has confirmed H5N1 (Avian Flu) in both cases. Confirm with the hospitals that this is the case.

Must do:
 Establish an Emergency Operations Center (EOC). Consider who needs to be involved in the EOC.
 Consider who else needs to be part of the EOC. Think Hospital and Elected Officials.
 Communicate with the leadership in other stakeholder groups about the threat that this pandemic represents.
 With others from the health department, create a unified message that needs to be communicated to the entire
community.
 Determine the best way to disseminate this message. Keep current through your epidemiologists about the number
of cases, high risk individuals and deaths.
 You are the leader and voice of the Pandemic response. While you will be supported by your PIO. It’s up to you to be
the Chief Strategy Officer and voice of the response.
 How will you support vulnerable populations?
 What will you recommend about masks in public places? Who should you ask?
 Share all of these tasks with the whole health department. You cannot manage this all yourself.

Operations Chief
You fill the role of Operations Chief in the incident command structure, and as such you are responsible for managing all
tactical operations at an incident. You will work directly with the Incident Commanders. You oversee the Epidemiologists
and Public Health Nurses in this role. Since the pandemic started, you have worked 10 hour days, 5-6 days per week. You
are a middle-age and live alone with your pets since your divorce 10 years ago. “I’m responsible for developing and
implementing strategy and tactics to carry out the Incident Objectives. This means that I organize, assign, and supervise
all of the tactical field resources assigned to an incident. I work very closely and coordinate my activities with the other
members of the Command Staff.”

Must do:
 Help run the Emergency Operations Center (EOC). Consider who needs to be involved in the EOC.
 Communicate with the Incident Commander and other EOC Chiefs to assure smooth operations.
Pandemic Avian Influenza Tabletop Exercise Stakeholder Small Group Roles 2023

 Your function is largely within the EOC, overseeing gathering of information from the epidemiologist(s) and
supporting the emergency response of the Public Health Nurses.
 With others from the health department, create a unified message that needs to be communicated to the entire
community.
 Determine the best way to disseminate this message. Keep current through your epidemiologists about the number
of cases and deaths related to Avian Influenza.

Planning Chief
You fill the role of Planning Chief in the incident command structure, and as such you are responsible for preparation and
documentation of the Incident Action Plan, in order to accomplish the incident objectives. You collect and evaluate
information, maintain resource status, and maintain documentation for incident records. You will work directly with the
Incident Commanders and other EOC Chiefs. The logistics Chief will contribute to the Incident Action Plan. Since the
pandemic started, you have worked 10 hour days, 5-6 days per week. You are trying to deal with criticism leveled by the
media and the community about the Incident Action Plan. You are married with 2 young children 4 and 7 years old. “My
job is to gather and analyze information so that we’ll be ready for tomorrow and the next day. I’m responsible for
intelligence and information gathering, analysis, and dissemination. Also, our section manages the planning process and
compiles the Incident Action Plan using input from the rest of the organization. I also may be responsible for managing
the activities of experts who can be anyone, from anywhere, who knows anything that may be useful in responding to
this incident. I work closely with the Incident Commander and other members of the Incident Command Staff to be sure
that information is shared effectively and results in an efficient planning process to meet the needs of the Incident
Commander and Operations Chief.”

Must do:
 Help run the Emergency Operations Center (EOC). Consider who needs to be involved in the EOC.
 Communicate with the Incident Commander and other EOC Chiefs to assure smooth operations.
 Your function is largely within the EOC, overseeing application of the Incident Action Plan and changes that may be
necessary based on information from the epidemiologist(s).
 With others from the health department, create a unified message that needs to be communicated to the entire
community.
 Determine the best way to disseminate this message. Keep current through your epidemiologists about the number
of cases and deaths related to Avian Influenza.
 Be prepared to tell your Logistics Chief what resources are needed.
 Incident Action Plan, Simplified:
o What do we want to do?
o Who is responsible for doing it?
o How do we communicate with each other?
o What is the procedure if someone becomes ill?
o NOTE: It is not necessary to create an Incident Action Plan for this exercise. These four elements are
included to help understand what needs to be done.

Logistics Chief

You fill the role of Logistics Chief in the incident command structure, and as such you are responsible for providing
support, resources, and all other services needed to meet the incident objectives. You will work directly with the Incident
Commanders and other EOC Chiefs, particularly the Operations Chief to make sure they have the resources needed. You
are the gateway to the Strategic National Stockpile. This includes Personal Protective Equipment (PPE) and anti-viral
medication. While there are sufficient supplies currently, you are concerned about distribution to first responders and
whether there will be future shortages. You communicate with the CDC regarding resource availability. You are involved
with the controversy about whether anti-viral medications should be used preventively by first responders and medical
personnel, or whether they should be reserved for those with the disease and high risk factors or serious illness.
Communicate with Emergency Medicine, Primary Care, Police, and Hospital Intensivists about how limited supplies of
anti-virals should be best used. “My job as Logistics Chief can make or break an incident response. I assist the Incident
Commander by providing the resources and services required to support incident activities. I coordinate my activities
very closely with the other members of the Command Staff. The Logistics Section supports development of the Incident
Action Plan, forwarding this information to the Planning Section.”
Pandemic Avian Influenza Tabletop Exercise Stakeholder Small Group Roles 2023

Must do:
 Help run the Emergency Operations Center (EOC). Consider who needs to be involved in the EOC.
 Communicate with the Incident Commander and other EOC Chiefs to assure smooth operations.
 Your function is largely within the EOC, overseeing application of the Incident Action Plan and changes that may be
necessary based on information from the epidemiologist(s). Find out what is needed from health department,
hospitals, primary care and emergency medicine and request those resources from the CDC Logistics Chief, overseer
of the Strategic National stockpile.
 Supervise Logistic activities related to:
o Medical services
o Food logistics
o Supplies
o Facilities
o Ground support

Epidemiologist (1 person)
You are epidemiologists at the Cuyahoga County Board of Health. You are responsible for tracking the epidemic and
reporting new cases to the EOC. This includes consultation with hospitals and Infectious Disease Specialists about the
contagiousness and severity of the virus. Go to the hospitals and Medical Examiner’s Office first to get this information.
You are a single young professional.

Must do:
 You are the primary liaison with the epidemiologist at the CDC. Seek each other out.
 Keep current about the number of cases and deaths. – no updates, globally we have 2000 -> need updates on
local/state/national numbers
 Communicate these with the incident commander.
 Examine patterns of illness related to Avian Influenza and inform those in charge of communication about who is at
highest risk of developing the infection and dying from it. At this point in the Pandemic, the R0 is 1.8 and Case Fatality
Rate is 20%. Highest risk patterns currently identified include pregnant women, children under 3 years, young adults
(18 to 26 years), over 55 years but greatest risk above 85 years, sickle cell anemia patients, the
immunocompromised, first responders and frontline workers, minoritized populations. In addition, Blacks are more
likely to have serious illness and death from Avian Influenza. You are one of the few people who begin this exercise
with this information. It is essential that you communicate it with the incident command structure and that Hospital
CEO. The hospital is aware of the R0 and Case fatality rates but not of who is at highest risk. Make sure this is
communicated through the Incident Command structure.
 Conduct modelling to predict the number and severity of cases. -> how to create modeling?
 You are in charge of contact tracing. Discuss how you intend to train and deploy contact tracers. ->
 Contribute to the unified message that needs to go out to the community.

Testing sites?
Contact tracing – train + deploy contact tracers? We have an online application system + training modules + zoom
training sessions -> looking at data from hospitals + testing sites
Spread through bug bites + respirator
Symptoms – cough, shortness of breath, fatigue, malaise, flu like symptoms

How long stay at home to isolate, guidelines, when to go to hospital – stay at home for 2 weeks after symptoms or after
hospital discharge
At home – monitor symptoms, fluids, social distance
Test – symptoms present or when we contact tracing
Severe symptoms/comorbidities/high fever

Public Health Nurse (1 person)

You are Nurses at the Cuyahoga County Board of Health. You are in charge of management of volunteer resources as
well. You are responsible for planning Points of Distribution (PODs). This includes distribution of antiviral medications
from the Strategic National Stockpile and planning for vaccine administration. These locations are previously planned and
Pandemic Avian Influenza Tabletop Exercise Stakeholder Small Group Roles 2023

distributed throughout the county and concentrated in high needs areas. You must begin to prioritize of who will receive
the limited resources. Consider consulting the hospital Bioethicist.

Must do:
 Your first task is to establish a Pandemic Avian Influenza Information Line that you need to disseminate widely. A
virtual place will be provided where questions can come in that must be triaged.
 Discuss a protocol for response to Avian Influenza questions. Anticipate FAQs and make a list of them. You do not
need to be able to respond to all of them, but do so when you can. Work with the PIO on this.
 Contact Community Emergency Response Team in the Community group.
 Discuss where Points of Distribution (PODs) should be established for when a vaccine or antiviral medication is
available. These locations are actually already previously planned and distributed throughout the county. You should
brainstorm where you think these PODs should be located.
 Create a preliminary list of high priority recipients of resources when available. Work with bioethics, healthcare
providers and the community to do so.

Public Information Officer (1 person)

You are The Public Information Officer(s) at the Cuyahoga County Board of Health. You are part of the Incident Command
Staff and report directly to the Incident commander. You serve as a conduit for information exchange to internal and
external stakeholders, including media. You monitor traditional and social media for disinformation. Your primary
concern is maintaining a unified message and limiting panic. You are concerned with communicating about who should
seek medical care and who should not; about how to communicate who has access to limited resources; and about
limiting misinformation. You are concerned about sensationalizing that is occurring on one local television network.
Internet rumors abound. The mission of public health is to educate and inform. The mission of the news media is to
entertain and inform. “I report directly to the Incident Commander and advise on issues related to information
dissemination and media relations. I am the primary contact for anyone who wants information about the incident and
our response to it. I serve both an external audience through the media, and an internal audience including both incident
staff and agency personnel. It’s very important for me to coordinate with other information staff to ensure that we do
not issue confusing or conflicting information. Since the Planning Section is gathering intelligence and other information
pertinent to the incident, I get a lot of my information from them. Accurate information is essential. In the end, the
Incident Commander will approve all information that I release. I recognize that the Incident Commanders are the face of
the incident, and that they are the spokespeople with the media.

Must do:
 Lead the process of creating a series of unified messages.
 Work with epidemiology from you LHD and from the CDC to craft this unified message about the current state of the
pandemic.
 Strategize about how to best distribute this messages.
 Strategize about who needs to be involved outside of the Health Department in creating the messages.
 Work with Public Health Nursing on the Avian Influenza Infoline protocol.
 You are in charge of social media. What messages do you want to put out there? How do you respond to
misinformation in social media? Use the Chat room for this exercise as social media for tweeting or messaging.
 What will you recommend about masks in public places?

Pandemic Prediction Checklist for CDC for Novel Avian Influenza TBL Exercise 2023

Note: Only National and Local Public Health have this information now. Share it however you choose, but make
sure the hospital leadership knows about the R0. and Case Fatality Rate.

[Link]

1. Transmission Route: is there an efficient transmission route, such as respiratory droplets, airborne
transmission or via the bites of common jumping or flying insects? Yes
Pandemic Avian Influenza Tabletop Exercise Stakeholder Small Group Roles 2023

2. Rapid Spread: Does it seem to spread rapidly within affected communities, going from a few cases to a major
local emergency within a month? If R0 has been credibly estimated, is the mean of the range higher than 1?
Yes, R0 is 1.8

3. Global Spread: Has it achieved community spread in non-endemic countries on at least 3 continents, and in a
set of countries comprising 15% of the world population (excluding endemic countries) and a total of 15% of
world GDP? Yes

4. Screening Difficulties: Is screening for the disease difficult due to test unavailability, unreliability, slowness, or
transmissibility that is highest in early/asymptomatic stages? Yes, testing is available but results are slow to
return.

5. Case Fatality Rate: A credible case fatality rate has been estimated, is it 1% or higher in at least 3 countries?
Yes, 20% overseas. Local rate is uncertain

6. Healthcare Overwhelm: Is there a concern about hospital overwhelm or medical supply shortages in
industrialized nations? Yes

7. Workforce Infection: Does the disease heavily affect career-age people (age 25-65), or frequently leave
survivors with lasting disability? Yes

8. Lack of Treatments and Vaccines: Is there no clearly effective treatment or vaccine? Treatment available, but
limited supply. No vaccine.

9. Demographics: If some non-age-related demographics are heavily affected and others are not, do the heavily
affected demographics amount to 15% or more of the population? If almost the whole population is about
equally affected, mark this criteria as met. At risk groups: Check with epidemiologists

10. GEOGRAPHY: Is the disease potentially transmissible across most of the world population? Yes

11. In The News: Has the disease made front page news on at least 3 different days in the New York Times in the
last 2 months, and also received the WHO designation "public health emergency of international concern" or
the equivalent? Yes

12. Quarantines: Has there been a quarantine of a city with over 1 million inhabitants? In a country comprising at
least 5% of world population or GDP, has there been a cancellation of major public events, or travel
restrictions on passengers arriving from or via this country? Yes

13. Pharma Sprint: Has the pharmaceutical industry begun a widespread research effort to produce a novel
treatment or novel vaccine, and/or has industry begun a major emergency effort to build physical
infrastructure or equipment (hospitals, ventilators, etc)? Yes

14. Death Toll: Have the death toll reached at least 2,000? Yes, globally. Not yet in the US.

Concerns our group holds regarding emergency

-Everything comes back to public health -> everyone (hospitals, services, national ie CDC) says we have information
and refers to us even though we did not always know things
Pandemic Avian Influenza Tabletop Exercise Stakeholder Small Group Roles 2023

-Making sure we had right, updated information

-Mental health concerns -> weighing both sides ie mental health vs safety of public

Actions our group would recommend to cope/mitigate the impact of epidemic

-Stay at home, masks, testing
-Form the group first and then have more organization + better flow of information
-Unified message

List bioethical dilemmas encountered by your stakeholders

-treating logistics chief or bioethicist when infected?

-vaccines/treatments given first to front line workers or first to those at highest risk?
-gathering for safety vs public health