Exercise Cold Play II

Please note that these outputs are intended solely for the purposes of this training exercise and should in no way be related to or inform any policy advice. Key parameters such as clinical attack rates, case fatality rate and vaccine efficacy remain unknown and may vary considerably in the event of a pandemic from those used in this exercise

1. Introduction

1.1 Background

Exercise Cold Play II is a Department of Health (DH) funded exercise designed as an ‘off the shelf’ package for use by health organisations and partner organisations within the UK. It has been developed from experience gained in previous pandemic influenza exercises and is intended to provide a generic format which can be adapted to suit the selected target audience. This exercise has been updated from the original Cold Play to ensure it is in-line with the Department of Health Pandemic Influenza Plan 2007.

The package is ‘owned’ by the Department of Health and maintained by the Emergency Response Department (ERD), Health Protection Agency (HPA) and is free of charge to health and other government organisations in the UK.

The Department of Health grant permission for copies to be made only for non-commercial use and it is a requirement that acknowledgement of the copyright is reproduced, e.g. “Crown Copyright/DH Copyright 2009 reproduced by kind permission of the Department of Health”

It is intended that the appropriate emergency planners in relevant organisations will facilitate the roll out of Exercise Cold Play II and liaise with interested parties in their region. Support is available from ERD should you need any advice please contact exercises@hpa.org.uk

1.2 Aim

To review the spring / summer H1N1v pandemic flu wave and to prepare for a more extensive second wave during this winter flu season.

1.3 Objectives

• Review the first wave (spring/summer)

• Assess pandemic flu plans and preparedness against national guidance

• Identify gaps and formulate actions to address those gaps

• Identify issues for recovery

1.3 Target Audience

This exercise is aimed at decision makers in organisations. Due to its generic nature the scenario and the questions in this exercise have the flexibility to be used by Strategic Health Authorities, Trusts, Ambulance Services and partner agencies either as a single organisation or in a mixed group.

1.4 Context

Under the Civil Contingencies Act 2004, designated responders have a legal responsibility to exercise and test the effectiveness of their plans and procedures. It is with this in mind and with the predicted extensive second wave of H1N1v pandemic flu during this winter flu season that this exercise has been created.

2. The Exercise

2.1 Exercise Design

Exercise Cold Play II has been designed for a delivery setting where all participants are seated at tables in one room. It is envisaged that the content of the exercise will be delivered by a facilitator through PowerPoint presentations.

Traditional ‘injects’ are replaced with questions that are included in Microsoft Word for distribution to participants. Subject headings, related to the questions, are provided in the opening PowerPoint presentation.

It is expected that the ‘off the shelf’ exercise will have the ability to evolve and will have the flexibility to meet the needs of your target audience and your local demographics and population.

Organisers and Facilitators are encouraged to add local information to increase the realism of the exercise.

2.2 Scenario

The scenario is based wholly on the spring/summer wave of H1N1v pandemic flu and how the predicted extensive second wave of H1N1v during this winter flu season may progress.

2.3 Exercise Format

Pre-exercise activities

It is suggested that each delegate is asked to do some preparatory work before the exercise. As a minimum this should be to review their organisation’s response to the spring/summer first flu wave and familiarise themselves with their relevant plans. Usefully, it could also include an identification of gaps in the plan with suggested resolutions and gaps, which couldn’t be resolved. These could then be brought to the exercise and discussed to highlight any gaps that remain and seek to address them by group discussion.

Exercise play on the day

Exercise Cold Play II is divided into four blocks of time; each block consisting of a single period in the progression of the pandemic from the end of the first wave through to a more serious second wave.

Each block is designed to bring out specific issues, so that many of the major topics surrounding an influenza pandemic are considered. So, whilst a number of topics may be relevant across all blocks (e.g. Civil Contingencies Act), each topic is only covered once.

Block One - Reviewing and preparing for the winter flu season

Block One will review the spring/summer H1N1v flu wave and consider the impact on organisations, the main issues arising and lessons identified and what could/ should have been done differently.

Block Two -Initial response in the second wave (early winter)

Block two requires the longest discussion period and focuses on anti-virals, the use of Personal Protective Equipment (PPE) and the arrangements for alternative health care once usual facilities are under pressure. There is also the opportunity to explore the resilience of the emergency services in this block.

Block Three - Business continuity at the peak (mid winter)

The pandemic is close to the peak of the second (extensive) wave with the health service under extreme pressure. The questions in block three focus on staff shortages and business continuity issues.

Block Four - Recovery (early spring)

As the number of new cases subsides towards normal seasonal flu levels, attention turns, especially in the media, towards recovery. The questions in block four focus on identifying the issues for recovery and capturing the lessons identified from the pandemic.

2.4 Exercise Questions

Each block contains a scenario, followed by a series of questions. All questions should be discussed and answered in order to ensure most of the issues surrounding an influenza pandemic are covered.

The questions are presented under subject headings. This will allow the facilitator the flexibility to pick and choose relevant questions that are appropriate for the chosen audience and that will fit with the timings of the day.

2.5 Exercise Assumptions and Artificialities

The exercise has been developed using the figures taken from the Department of Health National framework handbook (November, 2007) and planning assumptions published in July 2009 of up to 30% clinical attack rate and a case-fatality rate of up to 0.37% for the first wave.

2.6 Modelling

As part of Exercise Cold Play II a generic model for a dual wave scenario has been included, this lasts approximately 30 weeks from importation of the first case. It is not a planning model and is not to be used for this purpose.

The model is intended as a planning tool for your exercise. However you may choose to show the participants the model at the start of the exercise as part of an overview of the day. The model could also be useful for providing data during each block of the exercise if required. You may, of course, want to use your own modelling and figures for your local population.

The key assumptions within the model are:

• Population is 100% susceptible

• Average latency period is 2 days

• Average infectious period is 2 days

• Outputs are aggregated per week

The model, which is provided as a separate excel spreadsheet, shows the estimated number of clinical cases, deaths etc per week as a percentage of a population. The model allows you to amend parameters to reflect your population size and the severity of the pandemic that you wish to explore. You can also change the parameters to reflect what may have happened in the first wave as further details become available. The default value in the model for the first wave is based on the UK planning assumptions issued jointly by the Cabinet Office and the Department of Health on 16 July 2009. This assumes a clinical attack rate for the first wave of 30% and is the default maximum for this wave in the model. If in reality, the clinical attack rate is lower, this value can be changed to reflect reality more closely.

In addition, other parameters that can be changed to suit your own local population and requirements are:-

Population size

By adjusting the population size, the outputs from the model will automatically be adjusted.

Overall Clinical Attack

As noted above, the clinical attack rate for the first wave should be changed to reflect reality. The clinical attack rate can be adjusted, as required. The 50% default rate reflects DH reasonable worst case planning assumption prior to the emergence of H1N1v.

GP Consultation Rate

In the UK, an estimated 10% of clinical influenza cases present to General Practitioners with influenza-like-illness with additional numbers recorded as acute respiratory illness. This can be varied in the model based on expectations, but the default value of 20% represents the proportion of clinical cases expected to present to their GP.

Hospitalisation Rate

Estimated hospitalisations per clinical case for seasonal influenza are approximately 2%. During a pandemic, this may vary but this may be difficult to deduce, as it is dependent on health care facilities. The default value in the model is 3% of clinical cases but this can be varied as required.

Death Rate

Estimated deaths per clinical case for seasonal influenza are approximately 0.1%. This is similar to the previous pandemics of 1957 and 1968 but considerably lower than the 1918-19 pandemic. The death per clinical case (case fatality rate) in the H1N1v outbreak is tending towards 0.35% and this is the value used for the first wave. For the second wave, a default case fatality ratio of 2.5% has been used, but this can be adjusted as required.

2.7 Media

The package contains four video clips that contain mock media news broadcasts.

The four media news broadcasts provide visual updates on the scenario and are intended for use at the start of each block. They are useful as they help reinforce the context, but are not an essential element of the exercise and could be omitted if time was limited.

However, as part of the first media news broadcast there is an interview with Prof. John Watson, from the Centre for Infections, Health Protection Agency which explains some of the background facts about pandemic influenza. It is recommended that this interview is played at the start of the exercise to all participants as it is applicable to both health and multi-agency audiences.

To obtain a copy of the exercise DVD with the four video clips please contact your Strategic Health Authority Pandemic Flu Lead

When contacting them please provide the full name, email address, organisation details and full postal address, and the DVD will be sent by normal postage.

3. Exercise Documentation

The following documents are provided for the Facilitator:

• Guidance Handbook

• Introductory PowerPoint presentation

• Lessons identified/action template

• Generic modelling

The following documentation should be given to the participants as required:

• Scenario for each block; to be given to each individual

• Questions for each block; to be given to each individual

• Lessons identified/action template; to be completed by the relevant group

• Generic modelling; to be provided, if requested.

The following resources should be available at the exercise:

• Relevant health and multi agency plans

• Pandemic Flu - A national framework for responding to an influenza pandemic (DH)

• DH communications strategy

• Other relevant guidance and plans

How to access additional resource information can be found in Section 7 of this document.

4. Roles & Responsibilities

4.1 Participants

Exercise Cold Play II has the flexibility to be run as a strategic, a tactical or an operational exercise, depending on the needs of your audience. As the planner of your exercise, you are in the best position to make the judgement on who is appropriate to attend the exercise to meet your specific aims and objectives.

However, to ensure you get the most value out of the exercise, some recommendations are made below:

• Invite the relevant decision makers to the exercise.

• Ensure you have regional experts (e.g. regional epidemiologists, infection control specialists) playing in your exercise, so that they can answer specialist questions from other players, should they arise.

• Mix player groups for maximum participation and exercise flow, e.g. you may wish to mix geographic areas

• Limit player numbers. In order to ensure maximum benefit to all attendees we recommend a maximum number of 100 players.

Appendix A provides a list of possible organisations you may like to consider inviting to your exercise.

4.2 Roles

Facilitator

The role of the facilitator is to:

• Present the opening presentation

• Start the exercise by handing out the opening scenario.

• Direct the exercise by providing exercise inputs to the players; and

• Keep the scenario on track by focussing the participants on the questions to hand and working towards addressing the objectives.

• Provide situation updates and moderate group discussions.

• Provide additional information or answer questions, as required.

• Facilitate a feed back session

• Ensure the written debrief is completed and outstanding lessons addressed

• Report key learning to HPA ERD

Participants

Participants are expected to respond to the situations as presented, based on experience and knowledge as well as the current plans and procedures utilised within their organisations. Participants should ‘play’ as they would if the situation was real.

Observers

Observers are in a unique position to observe the exercise as it unfolds. They are expected to respect the needs of the participants to be able to work rapidly and openly, by being as discreet as possible unless they are asked to participate in the discussions.

5. Evaluation, Lessons Identified & Feedback

5.1 Evaluation

Objective and candid evaluation is critical to capturing the lessons that flow from exercise play and making the exercise experience beneficial for all. When evaluating the exercise the following are useful points to bear in mind:

• Consider the aims and objectives that have been set for the exercise

• Consider the processes and procedures during the exercise

• Consider the facilities and equipment available or used during the exercise

• Document errors and problems in the scenario or conduct of the exercise

5.2 Lessons Identified, Feedback & Reporting Procedures

Included in this package is a lessons identified/action plan template. It has been designed to be completed once each table/group has discussed the questions and agreed the way forward.

The template contains the exercise questions for each block. Against each question, the following columns are to be completed:

• Where evidenced in your own Plan(s)?

• Further Actions Required?

• Issues you can’t resolve that need cascading upwards & to whom

One great value of an exercise is that the lessons learned in one exercise can be shared with other colleagues and organisations. We, therefore, ask that all organisations that make use of Exercise Cold Play provide feedback and lessons identified through their emergency planner to HPA - Porton Down. We will, in turn, feed those lessons identified to the relevant government department be that Health, the Cabinet Office etc. Even if you feel the issues are being addressed through another route, please make us aware so that we can make others aware.

6. Exercise Organisation

6.1 Venue

Meeting Room

The facility should be large enough to seat comfortably all participants and make provision for observers. Sufficient parking should be available for all participants

A screen, projector and sound system/microphones will be required as will the capability to play a DVD.

It is recommended that the facility allows access to the exercise site for set-up either the day before, or early on the morning of the exercise.

6.2 On the Day

Registration

Set Up

Depending on the number of participants attending, it is recommended that registration is set up with two tables. The first is a main registration table to hold information packs laid out alphabetically. The second is a smaller table to be used for unexpected arrivals or for those who require a badge to be made up on the day.

Registration Staff

It is suggested that between two and three people staff the registration desk to ensure a smooth flow. Registration staff should:

• Familiarise themselves with the exercise content

• Familiarise themselves with the layout of the venue including toilets, refreshment areas, meeting spaces and identify any Health and Safety risks e.g. fire or trip hazards

• Ask to see identification from those participants who turn up unexpectedly and clarify how they were made aware of the exercise. If registration staff are unsure as to whether the person is allowed to attend, they should contact the event organiser.

• Welcome the participants, confirm the location of the opening session and advise where refreshments are available.

It is recommended that at least one member of the registration staff remains at the registration desk for a short time after the opening session has begun, to meet any latecomers.

7. Resource Section

7.1 Useful websites and documents

The following websites contain useful information on influenza:

Department of Health Pandemic Influenza Plan

The Health Protection Agency

Department of Health Emergency Planning - NHS contingency plans and advice on preparing for specific types of disasters and attacks

Influenza key documents and resources for patients and health professionals

NICE (National Institute for Health and Clinical Excellence)

The latest (2009) WHO global Pandemic Influenza Preparedness and Response Guidance document

The following guidance documents relate specifically to pandemic influenza:

Pandemic flu guidance for cleaning staff and refuse collectors in non-health care settings

Pandemic flu guidance for the hospitality industry

Pandemic flu guidance for the police service

Pandemic flu guidance for environmental health practitioners

Pandemic flu guidance for the Fire and Rescue Service

Pandemic flu guidance for funeral directors

Pandemic flu: human resources guidance for the NHS

Pandemic influenza: Guidance for Dental Practices

Pandemic influenza: Guidance on the delivery of and contract arrangements for primary care dentistry

Pandemic influenza: guidance on preparing mental health services in England

Pandemic influenza: Guidance for ambulance services and their staff in England

Pandemic influenza: guidance on preparing maternity services

London Regional Resilience Flu Pandemic Response Plan: Special arrangements for dealing with pandemic influenza in London

Government’s approach to a flu pandemic: planning and response

Pandemic flu: guidance for commissioners and providers of social care

This list is not exhaustive and continues to be added to all the time.

7.2 Ten Key Points about Pandemic Influenza

1. There are three types of influenza: A, B and C.

2. Types A & B cause seasonal influenza, which we see every winter; sometimes these produce epidemics with which we are all familiar.

3. Influenza type C is one of the many viruses that cause the ‘common cold’, and is of no public health importance.

4. Influenza A actually exists in the form of subtypes, for example: in 1968, subtype H3N2 emerged, known as ‘Hong Kong flu’ and in 1997, H5N1, known as ‘bird flu’ or ‘avian flu’. In 2009, the H1N1v subtype emerged known as ‘Swine Flu’.

5. If a new subtype of influenza A emerges virtually no one has any immunity.

6. If this new subtype also causes human disease and spreads readily from person to person, this produces a pandemic.

7. A pandemic is, therefore, more extensive than an epidemic and will spread rapidly around the world.

8. A pandemic virus may therefore cause more severe disease in more people.

9. Influenza A virus, like H5N1 (‘bird flu’), poses, what is known as, a ‘pandemic threat’; it can cause severe disease in humans but, at present, it cannot transmit easily from person to person. If it developed that ability, it would probably cause a pandemic. This can still happen and the threat has not gone away because of ‘Swine Flu’.

10. We can predict certain facts about the next pandemic even though we definitely cannot predict when or where it will occur. Nobody predicted Mexico as the source of the pandemic strain H1N1v.