4.7 Illustrative Example

The following example demonstrates how the concepts presented in this chapter may be applied during an actual incident response. The various phases of response (as described in Chapter 1) highlight when critical actions should occur; however, the example extends only as far as incident response operations, as this is the focus of the MSCC Management System.

Background and Incident Description

Jurisdiction Alpha is a city of moderate size whose western border adjoins another State.
A very sick patient with severe respiratory distress and a fever is admitted to a hospital in Jurisdiction Alpha. His admission was preceded by nearly three days of progressive illness with cough. During this time, he continued to work as a butcher in a small but popular meat shop. Since the patient had recently returned from an overseas trip to areas where severe acute respiratory syndrome (SARS) had reappeared, SARS is suspected and the jurisdiction's Department of Health (DoH) is notified.
The patient dies a short time after his admission to the hospital.

Incident recognition begins when the clinical suspicion is first reported to DoH and public health experts recognize the implications. Although it has not been confirmed, the suspicion of SARS is enough to warrant immediate actions by DoH, and a rapid health investigation commences. Epidemiological questioning quickly indicates that the patient (index case) had exposure to many customers at the meat shop after becoming demonstrably ill.

Notification/activation occurs when the DoH public health officer requests a management meeting with representatives from emergency management, fire/EMS, law enforcement, and public works. After a brief discussion, they agree to partially activate Jurisdiction Alpha's EOP for public health response (formal declaration of emergency is not required to activate portions of the EOP). The following actions also occur:

Using the jurisdiction's public safety communications center (as specified in the EOP), a written communication is sent to all agencies that automatically participate in the EOP. The notification only activates jurisdictional resources that are needed for the initial response.
An alert is issued to all HCOs in the jurisdiction (through Tier 2) indicating what is known about the demographics and recent history of the index patient, and any reported outbreaks elsewhere in the United States. The alert notifies Tier 2 assets that the jurisdiction EOP is partially activated.
A similar notification is provided to the State DoH, which notifies neighboring regions and the CDC using mechanisms established in Tiers 4, 5, and 6.
The mayor and city council are notified and immediately express concern. They recognize the potential human impact, as well as the implications for business and tourism. The mayor's PIO works with the DoH PIO to draft and immediately release a statement to the public explaining the jurisdiction's response.

Mobilization of jurisdictional resources occurs as the designated agencies activate their individual EOPs, and ramp up their staffing accordingly. Similarly, Jurisdiction Alpha's EOC is activated and staffed.

Incident operations are led by a UC that was designated in the initial management meeting. The UC is composed of selected individuals from jurisdictional (Tier 3) public health, fire/EMS, and law enforcement. The jurisdiction's public health authority is recognized as the "lead" UC agency. The UC coordinates closely with the jurisdiction's emergency manager, who manages the EOC (a MACC for the UC).

Management representatives from each agency in the UC conduct a teleconference to discuss what is known about the incident and to determine a course of action. It is decided that an ICP will be established at the DoH Operations Center, but UC members agree to transfer the ICP to the jurisdiction's EOC if management needs exceed the resources available at the DoH Operations Center. This backup is planned because multiple reports are coming in about patients with febrile illnesses reporting to HCOs. Many of these patients have recently visited the butcher shop in question.

Members of the UC quickly establish themselves at the ICP and coordinate the integration of their respective disciplines. Each agency maintains authority over its own assets, yet all contribute to the composition of the ICS Sections (Operations, Logistics, Plannings, Admin/Finance). For example, a senior DoH staff member directs the Operations Section, while personnel from other agencies manage specific branches (see Figure 4-2) under Operations.

A jurisdictional epidemiologist manages the Incident Epidemiological Profiling and Hazard Containment branches, with additional resources supplied by other agencies.
EMS manages Pre-Hospital Care.
A trained, experienced medical administrator pre-selected by thethe Tier 2 coalition serves as a senior medical advisor to the UC for issues related to hospital care. This role is designed to provide the hospital and medical practitioners' "perspective" when the UC is considering jurisdictional decisions that will affect the provision of incident-related medical care.
A jurisdictional medical examiner manages Fatality Care.

Expedited SARS serology tests from the index patient strongly indicate the patient died from SARS. Confirmatory testing is being conducted at the CDC. The rapid epidemiological investigation, aided by public service announcements asking anyone in contact with the meat shop to report to a DoH clinic for evaluation, has identified an extensive list of potential contacts. The contacts are given written instructions on the disease, its signs and symptoms, and precautionary measures. They are provided digital thermometers and arrangements are made to contact them daily for a health check.

Based on available information, the UC develops the first formal jurisdictional IAP for the next opertional period (designated as the upcoming 24-hour period starting at 7:00 a.m.). The jurisdictional IAP includes:

Control objectives for the overall response
Operational period objectives
Strategies for achieving the objectives, including:
- Disease containment for healthcare workers, identified contacts of the index case, and the general public
- Surveillance of the health of identified index case contacts
- Surveillance of HCOs and medical providers to identify other cases of possible SARS in the jurisdiction
- Contingency planning for medical surge needs (e.g., hospital isolation, critical care services, screening of concerned members of the public)
- Concise public information bulletins that are consistent across all tiers.
Response tactics, including:
- Twice daily telephonic screening of identified contacts, looking for early symptoms
- Educational information for identified case contacts
- Voluntary separation of contacts, with health personnel to assist and ensure that they maintain their separation from the public
- Educational information and personal protection supplies for family members who remain at home during the contact's period of voluntary separation
- Educational information for healthcare providers describing the early signs, symptoms, and physical findings of SARS. Contact information is also provided to report suspected cases, including how to obtain expedited serologic testing.
- Educational information for the public.
Situation status and resource status updates for the jurisdiction
Chart illustrating the jurisdiction's incident command organization, with the primary role of each agency and other significant participants specified; contact information is provided; the chart also demonstrates the relationship of UC to the EOC and to department operations centers.
Communications and safety plans, including DoH recommended protection (e.g., PPE, isolation, other protective measures for persons caring for potential SARS victims).

The jurisdictional IAP is shared with Tier 2 coalition members and State emergency management officials (Tier 4). The State, in turn, provides pertinent information to adjoining jurisdictions, bordering States, and to Federal public health personnel assisting in the State response. The operational period established by the State is adjusted so that State meetings occur one hour after the jurisdiction's (Tier 3) meetings. This phase-shift of Tier 4's operational period allows for coordination of operational briefings.

With the UC having defined its incident objectives and strategies through the jurisdictional IAP, other activities are identified for emergency management operations support to address through the EOC. These EOC responsibilities include:

Interfacing with the private sector (excluding hospitals, which are considered part of incident operations)
Interfacing with the State and the Federal Government (except for Federal health and medical resources that consult to, or work under, the jurisdiction's management system)
Determining school closures, addressing transportation disruptions, and managing other SARS impacts on the jurisdiction
Providing interface of UC with MAC Group (mayor and her senior advisors).

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