Facilitator Version - Ohio State University · 11, Armando Hoet . 1,2 * 1 The Ohio State University - College of Veterinary Medicine - Veterinary Preventive Medicine Department -

With support from: The Ohio State

University Extension and

The Centers for Disease Control and Prevention

Connecting the Dots

Megan D. Halcomb1, 2, Susan M. Skorupski3, Dan Harpster3, Oliver Fisher4, Tony Forshey5, Dennis M. Summers5, Amber

Singh 6, Nic Fisher7, Laurie M. Billing7, Brad Schwartz8, Richard Maier, Jr.9, Bryan Seamour9, James C Kile10, Timothy

Landers11, Armando Hoet 1,2 *

1 The Ohio State University - College of Veterinary Medicine - Veterinary Preventive Medicine Department - Veterinary Public Health Program; 2 OSU - College of Public Health; 3 United States Department of Agriculture - Animal and Plant Health Inspection Services -

Veterinary Services; 4 Auglaize County Health Department; 5 Ohio Department of Agriculture - Division of Animal Health; 6 Ohio Department of Health - Zoonotic Disease

Program; 7 ODH - Infectious Disease Informatics and Vaccine Preventable Disease Epidemiology (IDIVE); 8 Ohio Emergency Management Agency - Planning, Training and Exercise Branch; 9 Federal Bureau of Investigation; 10 Centers for Disease Control and

Prevention - NCIRD Influenza Division; 11 The Ohio State University - College of Nursing.

* Corresponding author: A188 Sisson Hall. 1920 Coffey Road. College of Veterinary Medicine, The Ohio State University. Columbus, Ohio. 43221. Phone 614-292-1206.

Email: [email protected]

August 2019

Facilitator Version

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Connecting the Dots… Introduction: This scenario is designed to present the early steps of a major zoonotic, infectious disease outbreak involving human and animal cases. You are a public health official working for “Buckeye County” Health Department in Ohio. The goals of this scenario include:

Learn what agencies and actions are involved in a zoonotic disease outbreak investigation with suspicious circumstances

Learn the risks and potential impact of an agriculturally important disease outbreak Learn the importance of inter-agency communication and a swift response to a

zoonotic disease with public and animal health implications

You receive a call from the Ohio Department of Health (ODH) to discuss a recent event reported by the Ohio Department of Agriculture (ODA). A large commercial chicken farm in your area that is experiencing increased morbidity and mortality has just confirmed an H7 avian influenza outbreak. The National Veterinary Services Laboratory (NVSL) has confirmed the H7 diagnosis as well, and responders have been dispatched to the farm from the ODA and U.S. Department of Agriculture (USDA) to manage the animal response.

There are suspicious circumstances surrounding the outbreak. Chicken carcasses of varying age and size which are obviously not from the farm were found inside the chicken houses. The farm owners, ODA, and USDA suspect an intentional disease event has occurred, possibly a disgruntled employee, and are exploring this possibility further. After the ODH and ODA have conferred, the ODH is reaching out to you, the local health department, to discuss the next response steps in your jurisdiction.

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The ODA notes the agricultural outbreak response has begun with state and USDA personnel responding to the site. Response activities following the Ohio Avian Disease Emergency Response and Containment Plan, which include: epidemiological investigation, quarantine of the farm, surveillance and zoning around the farm, traceability of animals, animal depopulation (destruction of animals), and disposal of poultry on the infected farm premises. Those responding are wearing Personal Protective Equipment (PPE) including: N95 respirators, disposable coveralls, shoe covers, and gloves. The responders are either working directly with the birds (direct contact) or are at a minimum on the quarantined premises.

a) Why is this a public health concern? b) What will be your role in this outbreak response? SUGGESTED ANSWER #1: a) H7 influenza viruses are a public health concern as some of these strains, such as

H7, have caused epidemics in humans abroad.(CDC,2018)

Typical “seasonal” influenza A cases in human infections involve types “H1” and “H3” viruses.(ODH,2019) If strains such as swine (H1N1v) or avian strains (ex: “H5” and “H7”) are detected in people, these are considered “novel” influenza A virus human infections.(ODH,2019)

b) You (LHD) and the ODH will collaborate in identifying, monitoring, reporting, and testing people with flu symptoms exposed to the infected poultry premises (responders and persons on the premises) from the earliest exposure, during the response, and until 10 days post-exposure (upon return to their residence).(Brown et al,

2018)

THE GOAL IS TO ESTABLISH WHETHER OR NOT ZOONOTIC TRANSMISSION OCCURS FROM THE INFECTED POULTRY TO THE EXPOSED HUMANS

Facilitator’s note: other actions that LHD may take (Brown et al, 2018) i. Surveillance in community for other human cases ii. Support for healthcare providers iii. Coordination of antiviral distribution

QUESTION #1

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QUESTION #2

Given this animal response information, the ODH requests your department begin organizing and planning to monitor for possible zoonotic transmission to the people exposed on the infected farm premises.

a) How should the exposed individuals be monitored for possible influenza zoonotic transmission?

b) What tests and samples will be required for persons who become ill? c) How are novel influenza cases in humans to be reported?

SUGGESTED ANSWER #2:

***FACILITATOR PLEASE READ THIS HIGHLIGHTED SECTION TO PARTICIPANTS: There have been revisions to the “Public Health Monitoring Plan for USDA/APHIS Responders to Detections of Avian Influenza Virus in Poultry” to include active and passive surveillance guidelines depending on the situation. Ohio’s draft plan on this guidance is currently under review. Active vs. passive monitoring would most likely be decided on a case-by-case basis and monitoring will most likely be divided into tiered exposure levels:***

a) The suggested monitoring may include: i. 1st, contact the exposed persons to assess and categorize their exposure levels, and

2nd, based on the exposure level, frequency of monitoring may be determined: For high risk exposure, active monitoring may be recommended: bird or

premises contact with a break in PPE or no use of PPE. (Brown et al & CDC, USDA-APHIS, 2018) Monitoring involved: Daily contact of exposed personnel during response and

10 days after last exposure (Brown et al, 2018 & CDC, USDA-APHIS, 2018) For low risk exposure, passive monitoring may be recommended: bird or

premises contact with PPE use. (Brown et al, 2018 & CDC, USDA-APHIS, 2018) Monitoring involved: “responders are asked to self-monitor and report any

illness to the safety officer during the response, or to the public health authorities for 10-days after their last exposure” (USDA-APHIS, pg. 3, 2018)

From 2014 - 2015, a HPAI influenza A(H5) outbreak occurred in the U.S. involving 15 states which included one of Ohio’s bordering states, Indiana.(US-GAO,2017)

Greater than 50 million birds were lost to the disease (died) or eradication control efforts (depopulation).(US-GAO,2017)

Dozens of countries placed trade bans on U.S. poultry products.(US-GAO,2017)

From the 2014 outbreak, estimates have been made that the total loss from depopulation, economic damages, etc… approaches $3.3 billion.(US-GAO,2017)

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ii. Maintain contact with the USDA Incident Command System Safety Officer for any changes in this process. (Brown et al, 2018 & CDC,USDA-APHIS, 2018)

b) The following tests and samples will be required: i. Symptomatic exposed persons need influenza subtyping by PCR testing to

assess if it is a novel influenza strain infection. (CDC, USDA-APHIS, 2018) Your LHD will coordinate specimen collection and submissions to the ODH lab.

ii. Virus identification can be done at the ODH lab. with confirmation testing at the Center for Disease Control and Prevention (CDC) influenza laboratories.(ODH,2019)

iii. Nasopharyngeal swabs transported in viral transport media are the preferred submissions for the PCR test. Other sample options include: nasal/oropharyngeal swabs, sputum, tracheal aspirate, and bronchoalveolar lavage.(ODH,2018)

iv. The ODH Lab. prefers samples be shipped overnight “for receipt within 24 hours.”

(ODH,2018)

c) Detection of animal influenza viruses in humans (“novel” influenza virus infections) are Class A reportable diseases in the state of Ohio.(ODH ,2018) “Class A: Report immediately via telephone the case or suspected case and/or a positive laboratory result to the local public health department where the patient resides. If patient residence is unknown, report immediately via telephone to the local public health department in which the reporting health care provider or facility is located. LHDs should report immediately via telephone the case or suspected case and/or a positive laboratory result to the ODH.” (ODH, 2018)

“The local health department should enter the case into the Ohio Disease Reporting System (ODRS) within 24 hours after the telephone report.” (ODH, 2018)

Over the weekend, response efforts were underway. Your department has been notified that two of the farm’s personnel have reported flu-like symptoms (one with a fever and cough, the other with conjunctivitis), but they have tested negative for flu A through rapid testing this morning. They will be monitored with further testing as needed.

Questions on Novel Influenza? Call the ODH Bureau of Infectious Diseases @ (614) 995-5599

Additional ODH information on Novel Influenza and Reporting: ODH Infectious Disease Control Manual (IDCM):

Influenza A Novel Virus Infection Section

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Now that your department has even more people to monitor, how will your organization manage the monitoring responsibility at this higher capacity?

QUESTION #3

On the agricultural side of the response, the ODA has received multiple notifications of other farms in the area, which have also experienced high poultry morbidity and mortality. Preliminary reports have revealed the farms are also H7 influenza positive. Another concerning finding is that these farms have no apparent connection (no shared company affiliation, no shared staff, no shared traffic from feed trucks, etc…). The newly infected farms are a mixture of small family-owned flocks and free-range chicken farms, which are all far apart with no overlapping zones. The total H7 flu positive farms, combined with the original farm, is now five farms. Now, there are a total of 250 exposed individuals on infected premises. Many of these individuals may require active monitoring.

SUGGESTED ANSWER #3:

Facilitator’s note: This is an open-ended question for participants to deliberate and brainstorm what they would do in their respective LHD. Each Department is quite different, so a fit-all suggestion is not available.

However, ask participants to consider the following points: • Utilize medical reserve corps volunteers? • Reach out to neighboring jurisdictions? • Ask for more state/federal assistance?

The ODA initially thought the farms may have been connected via wild bird cross-contamination. However, when they, along with the USDA Veterinary Services and the Foreign Animal Disease Diagnostician (FADD), visited the farms, several reported recent trespassing events. For example, one farm found tire tracks along their fence line a few days ago when they heard what they believed to be kids riding around on 4-wheelers at night. The free-range farm reported that they found chicken carcass pieces which appeared to have been tossed in with their flock, but they assumed it must have been some sort of prank.

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QUESTION #4

Given this new information of several new farms with suspicious findings, what could be a connecting cause of the outbreaks in these farms?

SUGGESTED ANSWER #4:

It is possible this could be an intentional disease outbreak such as an agroterrorism event. Supporting factors for this outbreak being caused by an intentional disease release are: The evidence found on the farms (strange tire tracks, trespassing, carcass pieces

which obviously did not belong to the farm).(DEMBEK,2007) The same disease agent producing multiple outbreaks in multiple locales.(DEMBEK,2007) A large number of animals dying in a region. (DEMBEK,2007)

Facilitator’s note: These suspicious findings would most likely prompt action by the ODA/USDA to contact law enforcement agencies

The ODA Animal Disease Diagnostic Laboratory (ADDL) and National Veterinary Services Laboratory (NVSL) have sequenced the original chicken farm’s H7 influenza samples and the strain has been identified and confirmed as Highly Pathogenic Avian Influenza (HPAI) Influenza

What is Agroterrorism? “The deliberate introduction of an animal or plant disease for the purpose of

generating fear, causing economic loss, or undermining social stability.” (USDA-OIG,2017) With over 2 million farms, more than $2 billion in crops, and over $1.8 billion in

production animals/animal products, the agricultural sector is a potential target for terrorism (USDA-OIG,2017)

Ohio, for example, has over 70,000 farm operations (total) and over 100 MILLION head of poultry as of 2018. (USDA-NASS, 2018)

“Terrorists seek to destroy, incapacitate, or exploit critical casualties, weaken our economy, and damage public morale and confidence.” - Homeland Security Presidential Directive.(USDA-OIG,2017)

“It is vitally important to protect the nation’s food and agriculture in order to ensure our health, safety, and economic well-being.” (USDA-OIG,2017)

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A (H7N9). Notably, the strain has been identified as an Asian lineage indicating the strain did not originate in North America.

This strain identification finding is a major concern as there have been no human or poultry cases of an Asian lineage H7N9 found in the U.S.(CDC,2018) Also, it is even more concerning as there have been over 1,000 people outside of the U.S. who have been infected with this very strain which may have been associated with rare human to human spread.(CDC,2018) It has become apparent that this disease outbreak is most likely an intentional agroterrorism disease release incident. Ohio has possibly been targeted to harm its human health, animal health, the economy, and the agricultural industry.

Based on this new information and the suspect bioterrorism potential, a large multi-agency meeting will be held. The meeting conference call is scheduled to take place in one hour.

Humans typically acquire influenza A (H7N9) through direct or indirect exposure to infected poultry or to virus-contaminated environments.(WHO,2018)

Highly Pathogenic Avian Influenza (HPAI) vs. Low Pathogenic Avian Influenza (LPAI) • The pathogenicity of avian influenza (high vs. low) relates to the severity of the

disease caused in poultry.(US-GAO,2017)

• HPAI strains causes a higher mortality in poultry.(US-GAO,2017)

Strains such as the H7 influenzas are capable of causing significant disease in humans and there has been some evidence of rare human-to-human spread incidents.(WHO,2018)

“As of December 7, 2017, the total cumulative number of human infections with Asian lineage H7N9 reported by WHO since 2013 is 1565. During epidemics one through five, about 39 percent of people confirmed with Asian H7N9 virus infection died.” (CDC,2018)

To date, there have been no human cases or avian cases found of Asian Lineage influenza A(H7N9) in the U.S.(CDC,2018)

HPAI A (H7N9) In 2017, HPAI A (H7N9) was detected in a commercial poultry flock in

Tennessee with 129,000 birds depopulated.(US-GAO,2017) This HPAI H7N9 was a North American lineage strain, not the Asian lineage strain found in parts of Asia. (US-GAO,2017)

Facilitator – You are halfway through the scenario – You have only 20 to 25 minutes left

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What agencies should be involved in this meeting and why?

SUGGESTED ANSWER #5: (not and exhaustive list)

AGENCY REASON

Buckeye Co. Local Health Dept.

(LHD)

The outbreak is occurring in the LHD’s jurisdiction. LHDs are the front-line first-responders of these investigations and will be involved in interviews, surveillance, and more.(IofM,2000)

Ohio Dept. of Health (ODH)

The ODH provides support to local health departments and surveillance/investigation of diseases and outbreaks.(ODH,n.d.)

Novel influenza A viruses are reportable to the ODH as some of these strains have the risk of reaching a pandemic status.(ODH,2019)

Local EMA &

Ohio Emergency Management Agency

(OEMA)

The Ohio EMA coordinates and facilitates state-level multi-agency response. The State’s Ohio Emergency Operations Center (State EOC) serves as a central facility for multiple agencies to coordinate incident response. As the Primary Agency for the Ohio Emergency Operations Plan’s Emergency Support Function #15 – Public Information and External Affairs - the Ohio EMA manages the State EOC’s Joint Information Center (JIC), which is tasked with producing unified incident-related communication and messaging. (OEMA,2018)

Centers for Disease Control

& Prevention (CDC)

The CDC is involved in surveillance efforts to monitor influenza strains which may impact human health & the CDC’s Influenza Division is also involved in influenza pandemic response/prep efforts. (CDC,2019) CDC Epidemic Intelligence Service officers may also respond to outbreaks and participate in field investigations.(CDC-

EIS,2018)

Ohio Dept. of Agriculture (ODA)

HPAI is an agricultural, zoonotic disease which is reportable.(USDA,2017)

ODA will be involved in investigating and responding to the outbreak in the agricultural side.

U.S. Dept. of Agriculture (USDA)

HPAI is a USDA-notifiable disease which can have a large impact on the poultry industry. (USDA,2017) The USDA will activate their HPAI Preparedness and Response Plan and assist the ODA in the animal outbreak. (USDA,2017)

Law Enforcement (FBI, Local)

Because there is a suspicion of agroterrorism/criminal activity law enforcement officials MUST be notified. Law enforcement’s involvement will be discussed in more detail later in this scenario.

Facilitator’s note: Most likely, law enforcement has already been involved at this point in the scenario.

QUESTION #5

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The multi-agency meeting begins with a situation report from each agency:

LHD & ODH: Your department and the ODH continue to collaborate with USDA safety officers to monitor response personnel on the original farm and are extending into the newly infected farms. So far, no positive human cases have been found. Your department and the ODH will continue human disease surveillance beyond the premises into the community with continued healthcare provider support and testing of any flu-suspect individuals.

CDC: The CDC has provided Epidemic Intelligence Service officers and a team of field agents. CDC will also continue to provide support to the local and state response and monitoring as ill individuals which require testing will be reported to the CDC by the ODH.

ODA and USDA: The USDA National Veterinary Services Laboratories (NVSL) has confirmed the chicken carcass pieces found in the original barn have tested positive for HPAI H7N9 Asian Lineage. The full-scale HPAI Response Plan has been initiated at all infected premises with quarantine, control zoning, depopulation, and carcass disposal.

(USDA,2017) The OIE (Animal World Health Organization) has also been notified, which will result in trade bans with a high economic impact to the industry and the state.

OEMA: The OEMA is prepared to facilitate the production of a joint press release from the responding agencies to inform the public of the current situation and the State Emergency Operations Center (EOC) is in partial operation status.

Law Enforcement: The local authorities and FBI have been collaborating with the ODA and USDA in investigating the suspicious activity. The strain of the disease does not fit the geographical region as there have been no human or animal cases of Asian lineage influenza A (H7N9) in the U.S. to date. This further supports the current suspicion that this could, indeed, be an intentional disease release (and agroterrorism attack). The remainder of the outbreak investigation will be considered an open case investigation.

The Incident Command System is fully activated at this time. Based on the agencies’ findings, the Ohio EMA will facilitate the production of a joint public press release in coordination with responding agencies’ the public information officers including your local health department, the ODH, ODA, USDA, CDC, and the FBI.

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a) What should be included in the press release? b) How should this communication process be facilitated?

SUGGESTED ANSWER #6:

a) For this press release the following information should include details such as: who, what, when, and where.(CDC-CERC,2017) What:

o Confirmed outbreak of influenza A (H7N9) in poultry. o Influenza A (H7N9) is a zoonotic disease & humans can contract it from direct

interactions with poultry and, very rarely, other people. o Symptoms people should call their doctor for: fever (101-102F), muscle pain,

cough, headache, sore throat, conjunctivitis, etc…(ODH,2019) o No human cases have been identified thus far. o Healthcare professionals should report suspect human cases to the Local

Health Department Who:

o List the agencies who are involved in the public health and animal investigation and their upcoming response plans.

When: o Describe a simple timeline of events.

Where: o Provide generic information about the location of the affected farms (like county

location), but do not provide specific addresses of the infected premises.

We must speak with one voice and care must be taken not to provide confusing, delayed, or varying messages. (CDC-CERC, 2018) o It is imperative to lessen panic related to the food supply, with statements such

as: “Proper handling and cooking of eggs and raw poultry should destroy AI.”(CDC,2015)

o Owners of sick poultry should contact their veterinarian/ODA to report suspect ill birds or bird mortality.

b) Information for the press release will be provided by the agencies involved through the State Joint Information Center (State JIC). o Joint press releases will be disseminated to the public via the State JIC. o Under emergency support function #15 (Public Information and External Affairs,

ESF-15) Ohio EMA staff would facilitate this communication process. (OEMA,2018) The State JIC “serves as a focal point for the coordination and dissemination of information to the public and the media concerning incident prevention, preparedness, response, recovery, and mitigation.”(OEMA,2018)

QUESTION #6

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As this is an active investigation of a suspected terrorism event with FBI involvement: a) What is the role of the FBI in the response? b) How should your LHD interact with the FBI in this investigation? SUGGESTED ANSWER #7:

a. The FBI has a lead Investigative Role accordingly to Presidential Policy Directive-25, which indicates: i. FBI would work in conjunction with LHD and all other agencies during this

investigation. ii. This would be considered a Joint Criminal-Epidemiological Investigation where

the information must be shared between criminal investigators and other responding epidemiological investigators from all the agencies involved in this outbreak response.

b. The LHD must take into account the following points when interacting with the FBI: i. The LHD should follow their normal chain of command/reporting to ODH, while also

maintaining an open channel of communication with the FBI. ii. The FBI can work with the LHD, and ODH, with responder contact.

iii. The FBI will rely on information accumulated by the LHD, ODH, and ODA/USDA during their own criminal investigation.

iv. The LHD, and other involved agencies, must be aware of the necessary information to maintain the proper chain of custody of evidence collected during their epidemiological investigation and response to the outbreak.

The ODA and the USDA are working to extend the control and surveillance zone perimeters. The OIE (World Health Organization for Animal Health) has been contacted and trade bans have been placed on our domestic poultry industry until the disease is eliminated. A swift response to “stamp out” this outbreak will be crucial to limiting this damage to Ohio’s economy and agriculture industry.

Since the press release, your department has begun receiving concerned phone calls with some potentially “worried well” and suspected flu-positive individuals. Unfortunately, despite the press release’s attempt to dissuade fear for this suspected intentional disease release, panic and suspicion have arisen.

QUESTION #7

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Your office, the ODH, and the CDC are contacting the large number of responders and personnel associated with the newly-diagnosed H7N9 chicken premises as well. With this surveillance, three individuals from the additional four premises have reported flu-like symptoms. These three individuals sought medical care and two have tested influenza A positive via in-office testing. Your office has requested samples from these individuals be sent to the ODH laboratory for subtyping of these cases to determine if they will be the first sign of zoonotic transmission in this outbreak.

If these influenza A (+) human cases are diagnosed with the H7N9 outbreak strain instead of the circulating seasonal flu, what effect will this have on the remaining of the public health response?

SUGGESTED ANSWER #8:

If indeed there is a zoonotic transmission of this outbreak strain, the public health response will have to surge due to the real potential of becoming a human health threat. Therefore, the effort will be focused on stopping the spread of this strain among the public. In that case, some of the actions that would take place are:

ODH will send an alert to the Ohio Public Health Communication System (OPHCS) to LHDs and healthcare providers, including the establishment of a case definition specific to person, place, and time to detect new cases not directly associated with the outbreak.

Continued monitoring of exposed persons (farm workers and response personnel) for disease development and potential spread to secondary cases.

Enhanced regional influenza surveillance.

More “flu kit” (testing supplies) distribution to LHD and region.

Monitoring of household (and other) contacts of confirmed (+) H7N9 human cases.

Because this is likely an agroterrosrism attack, if indeed there is spread to humans of this strain, this event will have major political and military implications for the country.

QUESTION #8

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Subtyping test results for the influenza A positive persons exposed have returned as human influenza A (H3N2) virus, which is the currently circulating flu seasonal strain in people. Further surveillance of those exposed to the infected bird premises and those in the community has indicated no evidence of a zoonotic transmission occurring between the infected birds and the persons who have been exposed thus far. Therefore, the investigation and response in general would still be mainly focused on the agricultural side.

CONCLUSION

In this hypothetical scenario, the suspicious findings were all interconnected by intentional, agroterrorism actions. The suspects found a way to illegally transport contaminated materials containing the H7N9 influenza strain into the state. They infected chickens with the pathogen in their own backyard flock and spread the infected chicken carcass pieces on to the targeted farms. The strange tire tracks, potential ATV noises, and suspected “prankster” teenagers were actually evidence of the bioterrorists getting access to farms across the state… all of this as pieces of A perplexing puzzle.

In this exercise, a full investigation occurred, and evidence was uncovered indicating that an intentional act of agroterrorism took place. It was thought that the goal of this attack might have been to cause economic damage to the poultry industry (from loss of birds and trade implications) and to produce fear of possible human disease. Fortunately, the strain used in this hypothetical attack did not successfully produce zoonotic transmission and human health was spared.

The present scenario described in this tabletop exercise was inspired by a natural occurrence (non-intentional) Avian Influenza A (H7N8) outbreak that occurred in 2016 in Indiana, which resulted in the depopulation of over 400,000 birds.(BROWN et al, 2018) This outbreak involved a multi-agency response, in which public health agencies actively participated by monitoring those persons exposed to the infected birds for signs of zoonotic transmission.(BROWN et al, 2018)

The current tabletop exercise was designed to highlight the need for multi-agency preparedness and communication in a large-scale, zoonotic disease outbreak. The scenario involved a familiar disease, Avian Influenza, in unfamiliar circumstances involving suspicious activity, an agroterrorism attack, and law enforcement agencies such as the FBI. If an outbreak occurs with suspicious circumstances, it is important to step back and look at the larger picture in order to connect the dots…

Final Group Question:

What did you learn today? What is the message to take home?

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Acknowledgements:

Special thanks to Barbara Bischoff, DVM, APR (Retired USDA-APHIS Veterinary Services) and Ronald M. Southerland, DVM, MPH, DACVPM (Area Epidemiologist, USDA-APHIS Veterinary Services, FiOps District 1) for their contribution in this endeavor.

References:

Brown JA, Patel R, Maitlen L, et al. (2018). Public Health Response to an Avian Influenza A(H7N8) Virus Outbreak in Commercial Turkey Flocks — Indiana, 2016. MMWR Morb Mortal Wkly Rep 2018;67:1339–1341. DOI: http://dx.doi.org/10.15585/mmwr.mm6748a2 CDC. (2015). Avian influenza current situation summary | Avian influenza(Flu). Retrieved August 11, 2019,

from https://www.cdc.gov/flu/avianflu/avian-flu-summary.htm

CDC. (2017). CERC corner—First message in a crisis. Retrieved August 11, 2019, from

https://emergency.cdc.gov/cerc/cerccorner/article_042617.asp

CDC. (2018) Crisis + Emergency Risk Communication (CERC) Introduction. Retrieved from

https://emergency.cdc.gov/cerc/ppt/CERC_Introduction.pdf

CDC. (2018, November 30) What EIS officers do Epidemic Intelligence Service. CDC. Retrieved August

11, 2019, from https://www.cdc.gov/eis/what-eis-officers-do/index.html

CDC. (2018, December 11). Asian lineage avian influenza a(H7n9) virus Avian influenza(Flu). (Retrieved August 11, 2019, from https://www.cdc.gov/flu/avianflu/h7n9-virus.htm

CDC. (2019, July 17) What CDC does about bird flu | avian influenza (Flu). Retrieved August 11, 2019, from https://www.cdc.gov/flu/avianflu/what-cdc-does.htm CDC & USDA-APHIS. (2018, June 15). Public Health Monitoring Plan for USDA/APHIS Responders to

Detections of Avian Influenza Virus in Poultry. Retrieved 8/12/19 from

https://www.aphis.usda.gov/animal_health/downloads/animal_diseases/ai/ai-monitoring-plan.pdf

Dembek, Z., Kortepeter, M., Pavlin, J. (2007). Discernment between deliberate and natural infectious

disease outbreaks. Epidemiol. Infect. 2007. 135: 353-371. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/16893485

Infections, I. of M. (US) F. on E., Davis, J. R., & Lederberg, J. (2000). Public Health Systems and Emerging Infections: Assessing the Capabilities of the Public and Private Sectors: Workshop Summary. Epidemiological investigation. National Academies Press. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK100248/

https://doi.org/10.17226/9869 Ohio Avian Disease Emergency Response and Containment Plan – Draft – Accessed 2019 Ohio Emergency Management Agency. (2018). Emergency Support Function #15 Emergency Public Information and External Affairs. State of Ohio Emergency Operations Plan. Retrieved from

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https://www.ema.ohio.gov/Documents/Ohio_EOP/ESF-15_emergency_public_info_and_ext_affairs.pdf Ohio Department of Health. (n.d.). Bureau of Infectious Diseases. Retrieved August 8, 2019, from

https://odh.ohio.gov/wps/portal/gov/odh/about-us/offices-bureaus-and-departments/bureau-of-infectious-diseases/bureau-of-infectious-diseases

Ohio Department of Health. (2019). Influenza A, Novel Virus Infection. Infectious Disease Control Manual (IDCM) Section 3. Retrieved August 7, 2019, from https://odh.ohio.gov/wps/portal/gov/odh/know-our-programs/infectious-disease-control- manual/section3/section-3-flu-novel USDA-APHIS-VS.(2017).Highly Pathogenic Avian Influenza Response Plan The Red Book. Foreign Animal Disease Preparedness and Response Plan. Updated May 2017. Retrieved from https://www.aphis.usda.gov/animal_health/emergency_management/downloads/hpai_response_plan.pdf USDA NASS. (2018). State Agriculture Overview for Ohio. (2018). Retrieved August 19, 2019, from

https://www.nass.usda.gov/Quick_Stats/Ag_Overview/stateOverview.php?state=OHIO

United States Department of Agriculture Office of Inspector General. (2017). Agroterrorism Prevention, Detection, and Response. Audit Report 61701-0001-21. March 2017. Retrieved from https://www.usda.gov/oig/webdocs/61701-0001-21.pdf United States Government Accountability Office. (2017). USDA Has Taken Actions to Reduce Risks but Needs a Plan to Evaluate Its Efforts. Report to Congressional Requesters. AVIAN INFLUENZA. 2017. GAO-17-360. Retrieved from https://www.gao.gov/assets/690/684086.pdf World Health Organization. (13, November 2018). Influenza(Avian and other zoonotic). Retrieved August 11, 2019, from https://www.who.int/en/news-room/fact-sheets/detail/influenza-(avian-and-other-zoonotic)

Final Note: Answers to exercise questions were based on:

- Research including reference listed above and an extensive science-based literature review, and - Discussion of the members of the development team