CDC tests pandemic readiness in drill that
pretends bird flu cases are in U.S.
http://www.canada.com/topics/news/world/story.html?id=405b778d-4378-469b-9a9e-afdd84d0c228&k=72478
Helen Branswell, Canadian Press
Published: Saturday, February 03, 2007
ATLANTA (CP) - As they settle into assigned seats in a small conference room in Atlanta, the fictional scenario laid out for the most senior emergency and infectious disease experts at the U.S. Centers for Disease Control is grim.
A gravely ill Indonesian man who has just returned to Washington, D.C., from Jakarta has tested positive for H5N1 avian influenza. The 22-year-old student was infected by his father, a confirmed H5N1 case who had since died.
Two of the student's housemates are ill; three members of his swim team are also sick. Complicating matters, the swim team has travelled by bus to New York City for a competition and is now quarantined there in a hotel.
Two travellers who were on planes with the student have fallen ill. A man has died of acute respiratory distress syndrome in a Chicago hospital; a woman in Maryland is suffering from milder flu symptoms.
It is 8:30 a.m. Wednesday, and the United States appears to be one of the first countries hit by an emerging influenza pandemic. The news is sobering but the picture murky - just as it would be in the first worrisome hours and days of a pandemic.
It is, however, just an exercise. More than 300 CDC employees are taking part in what is supposed to be a 24-hour drill Wednesday and into Thursday morning, simulating how spread to and within the U.S. might unfold and how the agency would respond.
In the high-tech but crowded Director's Emergency Operations Center and adjacent break-out rooms, staff begin deploying disease investigation teams to Washington, New York and Jakarta. In acronym-laden CDC-speak, the facility is known as the DEOC, which is pronounced as DEE-ock.
All major outbreaks are managed out of the DEOC. It's not just a facility, it's a state of dread for staff called to abandon their offices and their daily routine to join crisis management teams for exhausting crises like 9-11, the anthrax attacks, SARS, the monkeypox outbreak and Katrina.
"This is important stuff. We're going to learn a lot. That's the point," CDC director Dr. Julie Gerberding says as she kicks off the exercise, noting if staff don't push themselves to the point where they make mistakes, "we won't learn anything."
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8:30 a.m.: Gerberding and designated senior staff meet in the director's conference room, one of several ringing the DEOC. Included are the heads of the emergency response and quarantine divisions, the head and deputy head of influenza, the agency's chief science officer and other key players.
The group learns that at 8:24 a.m., the president moved the U.S. up one notch on its pandemic staging ladder, a step closer to a pandemic.
After being briefed, Gerberding raises a series of questions and asks the experts to get staff to work on addressing them. Among them: Do embassies abroad need evacuation plans for Americans overseas?
Recommendations need to be drafted for the U.S. Secretary of Health, Michael Leavitt, on possible interventions and on whether a public health emergency should be declared. There is ready agreement the declaration is necessary.
Dr. Rich Besser suggests the group needs to discuss the best timing for shipping the drug stockpile to the states, which are given a share based on their percentage of the national population. Moving the drugs early, while truck drivers are healthy and relative calm prevails, would be easiest, says Besser, director of terrorism preparedness and emergency response operations.
Dr. Marty Cetron, head of global migration and quarantine, puts the question of border strategies on the table.
Cetron too pushes for pre-emptive action, saying if border screening is to cut down on the introduction of new cases to the U.S. it must be activated early. He warns the World Health Organization may ask the U.S. to screen outgoing travellers to lower the risk Americans might further spread the virus.
In contrast to Besser and Cetron, Dr. Nancy Cox and Dr. Dan Jernigan are cautious. The head and deputy head of the influenza branch respectively, they would like to see evidence of spread elsewhere before assuming the pandemic threat has increased.
Gerberding tells them she's privy to classified information she can't share because several in the room don't have the necessary security clearance. "I believe he is correct," she says of the president's decision.
As the meeting nears the one-hour mark, Besser gets word the Indonesian student has died.
Gerberding says CDC needs to reach out to its counterparts in Canada and Mexico. "We'll need them to be equally vigilant."
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9:50 a.m.: As the meeting breaks up, someone notes freezing rain is forecast for overnight.
That's no small threat in a city where cars don't have snow tires, drivers aren't used to winter conditions and the city doesn't plow or salt the roads.
Gerberding wryly quips that this is "an unintended inject" - the term drill planners use to describe the more than four dozen developments and curve balls they intend to introduce as the exercise unfolds.
There is rich irony in cancelling a drill because something unexpected and negative happens. And yet there is immediate recognition this will probably happen. The CDC brass won't risk the health of staff for a drill.
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9:55 a.m.: Gerberding adjourns to a tiny private office with a video phone to call Health Secretary Leavitt. The news, she tells a person playing Leavitt, is concerning. "It's very unlikely we're going to be able to put this genie back in the bottle."
Gerberding suggests immediate activation of a pre-existing plan to put a small group of key decision makers in Washington on flu drugs to keep them from becoming sick to ensure continuity of the government. The CDC also believes Washington should declare a national public health emergency.
10:10 a.m.: Gerberding steps out of drill mode to explain why the CDC is running the exercise and why a handful of print media reporters are being allowed to observe the event.
Simulation exercises like this one - alas, it has no catchy code name - show CDC where its planning works and where it falls short.
There are significant concerns within the agency about the idea of allowing reporters "inside the sausage factory while the sausages are being made," Gerberding admits. But she says the agency wants "to be transparent and open about our learning."
She and Besser set the stage, though, for possible failures. He points out most of the people now manning stations in the DEOC have never before worked in this facility, which is just over a year old.
Gerberding notes that in evolving situations, people have to get comfortable with making decisions on partial information, and then adjusting as more of the picture comes into focus. "This is adaptive reasoning, adaptive decision-making. And we learn as we go and we adapt and update as we go."
"It's very difficult for some people to do that. Some people want to have all the information before they make a decision."
She shares some basics of how it's done.
"Don't make decisions that you don't need to make. But if you feel that a decision can be made, make it. If you feel like something could change and you would have to adjust that decision, acknowledge it."
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10:50 a.m.: Back in her conference room, Gerberding is calling to consult with the WHO in Geneva.
As she waits for the call to be put through, the CDC director notes the room has a deliberately "parsimonious" supply of chairs - maybe 15. Extra chairs are magnets for extra bottoms. In times of crisis, only those staff the director needs are welcome in the room.
The WHO deputy director general says a meeting is planned for Friday to decide if WHO should raise the global pandemic threat level from the current Phase 3 to Phase 4. Gerberding suggests the meeting should be brought forward.
She outlines the U.S. situation. "We strongly suspect this represents person to person to person transmission."
The WHO asks CDC experts for a team to be deployed to Indonesia through the WHO's Global Outbreak Alert and Response Network, known as GOARN.
After the call ends, Gerberding notes security could be a concern for the GOARN team, given the situation on the ground in Indonesia where hospitals are reportedly being overwhelmed. "Make sure it's up to our standards," she insists.
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Around the DEOC, people are making calls and firing off e-mails, checking the status of the investigations into the health of contacts of suspected cases, liaising with counterparts in state public health departments, assessing supplies of antiviral drugs, ventilators, masks for health-care workers.
Communications staff are working up talking points for a press conference Gerberding will hold later in the day. They are also making plans with CDC security for what they expect will be a long-term invasion of reporters who will expect daily access to CDC press briefings and experts.
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In a room several storeys above the DEOC, about a dozen men - many former military personnel - are pulling the strings of the drill.
They are monitoring how staff are dealing with the situation, adjusting the complexity as needed.
"We've got a rheostat on this. We can crank it up. Or we can crank it back," says retired Lt.-Gen. Pete Taylor, program manager for MPRI, the company contracted to run this exercise.
It's one of three the CDC will conduct in the first half of 2007, and it's meant to be the easiest. A later drill will see a significant portion of CDC staff out sick, a situation the agency knows it would face in a pandemic. The description of the intent of the escalating drills - Crawl, Walk, Run - is repeated often.
Because this exercise involves only CDC staff, calls that would normally go to outside contacts come to this room instead. The command centre is trying to ensure information flows as it would in a real event.
"If it takes about half an hour to give them that information, we hold on to it for about half an hour," says Jerry Jones, a retired lieutenant colonel.
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4:20 p.m.: Gerberding holds her first news conference on the situation. Press office staff are standing in for real journalists, though the orderly way they take turns asking questions doesn't conjure up the tension that would saturate the event if this were the real thing.
She shares the news that a fatal case of H5N1 has been confirmed in the U.S., that some contacts are ill and others are being screened, but she is parsimonious with details and the ersatz journalists don't drag them out of her.
"We're very early in our understanding of the situation in the United States and in Asia," she says, but adds "this represents a situation consistent with a pandemic threat."
Gerberding says the agency plans an aggressive response. The term "leaning forward" peppers her speech all day. But the CDC will dial back if the early concern proves to be unwarranted, she says.
After she wraps up the session, Gerberding briefly slips out of drill mode. "Well, I hope I never have to do this," she remarks.
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5:20 p.m.: Senior staff gather for Gerberding's second briefing of the day.
There are four confirmed cases, one in Washington and three in New York. Test results are pending on two others. Four more people are positive for influenza; further tests will tell if it's H5N1 or regular flu. Two teenage children of the Maryland woman - one of the plane passengers - are showing signs of illness.
Three people are dead.
"None of the news here is good," Cetron remarks.
A flight from Singapore with a sick patient onboard has been quarantined in Hawaii. Lengthy discussion follows about whether incoming international flights should all be funnelled to one of the 20 U.S. airports with quarantine operations.
Cetron, the head of quarantine, is keen. But Jernigan, the No. 2 in the influenza division, wonders why CDC isn't hearing about more countries involved. The fact that so few swim team members have fallen ill also gives him pause.
Gerberding tells her team the consequences of taking this action are enormous: "We will have changed policy and that's going to send a very strong signal."
"This is going to be one of the hardest decisions we're going to have to make," she warns the group.
In the end, Gerberding asks Cetron to draw up a document outlining the pros and cons of a variety of options. The document, which he promises within hours, will be sent to Health Secretary Leavitt. The CDC can only advise on this decision.
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6:30 p.m.: As the briefing breaks up, the numbers and the noise in the DEOC swell. Staff scheduled to work the 7 p.m. to 7 a.m. shift of the drill are arriving and milling about waiting to claim spots as the day team vacates. The open portion of the drill is over and the journalists are asked to leave.
