The simulation provided a rich forum for dialogue and debate and generated a number of lessons learned. The major lessons and policy recommendations are outlined below, by exercise goal.
Goal 1: Build relationships with participants from key organizations.
Exercises of this type typically yield lessons that can be applied at both the individual and the institutional, or systems, levels.18,19
With regard to the former, players affirmed the importance of personal relationships and contacts and the need for preestablished communication channels to promote and facilitate information sharing, coordination, and operability across disciplines and jurisdictions. Linkages between academia and public health agencies differed by state; most participants agreed that the connection varies from community to community and depends largely on local structures and relationships. Recurring questions centered on uncertainties about when and to whom to report an outbreak. In a situation with no hospitalizations and no deaths, most opted for an informal process—that is, discussions with university administrators and clinical colleagues, rather than official notification of public health authorities. Generally, even as the outbreak escalated, players continued to rely on informal communication networks and preexisting relationships rather than official reporting channels.
Emergency communications plans and information-sharing mechanisms of some of the agencies represented seemed robust at the institutional level, but the exercise revealed many gaps in communication with other institutions and agencies. Once the outbreak began to spread beyond the initial focal area, the need for better communication and coordination across disciplines and jurisdictions—and formal protocols for these—became apparent. In particular, the group advocated for establishment of protocols for information sharing among university, public health, and emergency preparedness and response entities at all jurisdictional levels, particularly regarding sharing of information related to epidemiologic investigations. They emphasized the need to establish formal relationships with local and state public health partners in advance of a crisis to smooth the communications process during an emergency and to maintain open channels for informal information sharing.
Risk communication was recognized as a key component of the initial response. Players agreed on the need to be prepared with a contingency press statement that acknowledged the uncertainties surrounding the event and summarized the ongoing investigation. Participants noted the potential usefulness of unique communication tools available at universities (eg, university-wide e-mail and text notification systems, listservs for student health directors) that could be used to deliver messages crafted in a way most likely to resonate with the community they serve. Questions were raised about when and how to use these systems to their best advantage. SECEBT was identified as a resource for formalizing communication within the region.
Goal 2: Identify and alleviate gaps in existing surveillance plans, policies, and procedures.
The exercise raised other important issues relevant to agencies and institutions. Key among these was the uncertainty about whether and when leadership should be transferred to and/or shared with local and state health departments and federal agencies such as the Centers for Disease Control and Prevention (CDC) and the U.S. Department of Agriculture (USDA). Participants urged development of trigger points for notifying the “next level” of responsibility as events evolve during an outbreak, as well as triggers for information sharing among university, public health, emergency response, and law enforcement entities at all jurisdictional levels. Trigger points should be defined and agreements put in place before an event occurs.
Once the disease was confirmed as toxoplasmosis, all institutions accelerated their responses. Academic players recommended increasing situational awareness by communicating with the university community about the presumptive diagnosis and providing information and prevention guidelines. They also recommended that universities be included on distribution lists for alerts from local and state health departments. For health departments, next steps were to strengthen active surveillance and focus epidemiologic investigations. The nature of this outbreak also demonstrated the need for collaboration with federal agencies, including CDC, USDA, and the Food and Drug Administration (FDA).
There was no concurrence on the need for an incident command structure (ICS). In some participating states, ICS is the standard for response to all outbreaks, whereas in others the decision to initiate the ICS process depends on the level of concern associated with the outbreak. Several participants noted the need for more practice with the incident command structure during “smaller” events.
The exercise scenario also required players to consider roles and responsibilities for epidemiologic traceback of food products to identify sources of contamination and limit the public health threat. State representatives reported much variability and vagueness regarding leadership in epidemiologic traceback. USDA has no regulations, standards, or requirements specific to toxoplasmosis and no authority or activities to test for an endemic disease in a clinically healthy animal. Therefore, the group recommended against testing and advocated focusing instead on public education about food handling and restoration of consumer confidence. These efforts require collaboration between agriculture and public health partners to ensure consistency of messages during an ongoing investigation. Any action by USDA will center on helping the affected companies by assisting with good production and biosecurity practices as appropriate.
When the exercise revealed the international aspect of the outbreak, the discussion turned to food regulations. Most participants were unclear on USDA regulations regarding importation of meat products. Several voiced a need to foster communication with regulatory agencies such as USDA's Animal and Plant Health Inspection Service and Food Safety and Inspection Service. Also, although most practitioners are likely to be familiar with the outbreak organism, few will have encountered the implicated atypical strain from South America.17,20,21
Some participants questioned whether such an outbreak should be considered a public health emergency of international concern requiring notification of the World Health Organization under the International Health Regulations.22
Most agreed on the need to engage the Pan American Health Organization and the Ministry of Health in the country of origin of the implicated pork.
Goal 3: Recognize the unique contributions that academic institutions can make to outbreak preparedness, investigation, and control.
Players agreed that, by leveraging the traditional roles of education and training, research, and patient care, universities can be a force in outbreak recognition and response. Within geographic regions, universities are also uniquely positioned to work with other stakeholders to ensure or develop an integrated strategy. In the current era of biothreat preparedness, academic institutions can play key roles in developing emergency preparedness exercises and after-action reports, answering applied research questions arising from these reports, and developing and testing best practices. Beyond these training and research functions, academic institutions can play an operational role in responses through their multidisciplinary service arms (eg, training institutes, patient care sites for unusual or complicated infections, plant and animal health services).
Participants observed that academic institutions are relatively rich in resources compared to local and state health departments and have untapped reserves to bring to emergency responses. These include human resources that can augment the public health workforce, clinical and research facilities that can augment laboratory capacity, and mechanisms for crisis communication that have great penetration and are regarded as credible. For example, students and faculty from schools of public health, medicine, and nursing can assist in disease investigations, and business school faculty and staff can help health departments improve management skills. University capacity and resources in diagnostics and genotyping, as well as journalism, communications, and law, can be harnessed to strengthen outbreak response capacity. Many universities have integrated practical programs to address the needs of public health preparedness and emergency response.23,24
Also, initiatives such as Emory University's Student Outbreak Response Teams (www.sph.emory.edu/sort
), the University of Minnesota's Team D (www.sph.umn.edu/outreach/engagement/teamd.asp
), and the University of North Carolina School of Public Health Team Epi-Aid (http://cphp.sph.unc.edu/teamepiaid/index.htm
) can be replicated to organize and integrate surge capacity before an emergency. A review of responses to federally declared disaster events between September 11, 2001, and February 1, 2009, concluded that academic institutions' participation in community disaster response has contributed to community resilience and the achievement of specific dimensions of disaster preparedness and response.25