Three Corner Point Exercise

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1 Three Corner Point Exercise Cross-border Exercise Report Heerlen, The Netherlands 2 October

2 Executive Summary Part 1 Introduction A. Background B. Aim and objectives C. Scenario D. Participants in the exercise E. Contact person Part 2 Conduct of the exercise A. Exercise design B. Exercise location C. Exercise date and time schedule D. Format E. Photos Part 3 Evaluation of the exercise A. Positive experiences B. Key issues identified and lessons learned C. Recommendations Part 4 - Conclusion Appendix A.. Appendix B Appendix C. (introduction/purpose, participants, main issues..) A. Background Transborder outbreaks and pandemics are happening much faster than before. Therefore there is an urgent need for rapid transnational detection and response as well as an improved international collaboration and integration of surveillance and response systems, especially in crossborder areas. The EMRIC+ project (Euregion Maas Rhine Intervention during Crises) has facilitated the development of an improved and structured cross-border cooperation network resulting in a more adequate euregional infectious disease surveillance and control, as well as a better disaster preparedness and response. Several cross-border infection control instruments were developed during the course of the project. 2

3 The Three Corner Point Exercise was part of the EMRIC+ project. It offered the participants who were coming from Belgium, Germany and the Netherlands the possibility to interact and to increase understanding and awareness of cross-border aspects of infectious diseases control. This table-top exercise allowed the participants to cooperate on a transborder food-borne outbreak, while testing the EMRIC+ instruments. This report outlines the conduct of the Three Corner Point Exercise and decribes the observations, key issues, evaluation and recommendations resulting from the exercise. B. Aim & Objective The aim of the exercise was to explore cross-border coordination in infectious diseases control and response to a cross-border outbreak. The exercise emphasized on the crossborder communication and the information exchange process. Specific objective was to test and discuss the Instruments that were developed during the course of the project. These Instruments are: 1. Euregional protocol with agreed Actions, 2. Agreed Minimal Data Set (MDS) for Cases, Outbreaks and Exposure, 3. Cross-border Risk Alert Levels (CRAL), 4. Cross-border Notification Template, 5. Cross-border Dashboard. C. Scenario The exercise was designed to represent a 14 week period in an evolving cross-border food-borne contamination event in the Maas-Rhine Euregion with with secondary humanto-human transmission taking place. The scenario was based on the contamination of pomegranate seeds (in a frozen berry mix). Cases of infection occurring in different age groups would necessitate exchange of information and cooperation between the public health authorities in the Maas-Rhine Euregion in order to confirm and control the outbreak. 10 total of confirmed cases secondary MSM M51 M42 M daycare secondary restaurant secondary household confirmed cases 3

4 Phase 1 started with several hepatitis A notifications over a period of several weeks in all three countries in the Maas-Rhine Euregion. Five Dutch cases and one German case were related to a Dutch daycare center (the index case who had traveled to Maroc and five secondary cases), confirmed by viral genetical analysis. The press showed a minor interest in these cases. More people in the Euregion fell ill with hepatitis A. Viral genetical analysis showed another hepatitis A type than fore those cases related to the daycare center in the Netherlands. Confirmed cases in all three countries became evident with food histories supporting a link to a Belgian supermarket. By now the press is pressurizing the public Health Services, especially since a few patients were hospitalized and the occurence of one death. In phase 2 it became clear from the case-control study that a certain frozen berry and pomegranate seeds mix bought at a Belgium Supermarket chain (four locations in the EMR: three in Belgium, one in Germany) was the origin of this outbreak. The number of cases continued to increase, including secondary infections by person-toperson transmission. Two more cases were hospitalized and another person died. Three secondary cases were infected by MSM contacts in a Dutch sauna, introduced by a Belgian case. Another case turned out to be a secondary household infection (Germany). One case working at a fastfood restaurant in Germany infected four customers. By combining information from the Belgian food authority s traceback and traceforward investigations and the public health units epidemiological investigation, the most likely vehicle for the hepatitis A virus appeared to be a common shipment of pomegranate seeds from a certain Turkish company. These seeds were used by a Belgium company making the Organic Anti-oxidant Blend. A prompt and structured cross-border cooperative response (vaccination, investigation, information to the public, press contacts and recall of the product) was needed to stop the outbreak. In total fifty-eight persons with hepatitis A were identified. D. Participants in the Exercise Communicable Disease s and nurses working at the Public Health Services / Department Infectious Diseases Control in Belgium (Antwerpen, Hasselt), Germany (Aachen, Heinsberg, Euskirchen) and the Netherlands (Heerlen, Geleen, Maastricht, Roermond and Venlo) were invited to participate in the exercise. Also representatives from the Department of Environmental Health (Heerlen) and the Regional Medical Assistance Organization (Maastricht). 4

5 E. Contact Person Henriëtte L.G. ter Waarbeek, MD Head Infectious Disease and Tuberculosis Control Projectleader Cross-border Infectious Diseases Control (EMRIC+) T +31 (0) M +31 (0) M W Department of Sexual Health, Infectious Diseases and Environmental Health, Public Health Service South Limburg, PO Box 2022, 6160 HA Geleen, The Netherlands Faculty of Health, Medicine and Life Sciences, Department of Medical Microbiology, Maastricht Infection Center (MINC), Research School CAPHRI, Maastricht University Medical Center, PO Box 5800, 6202 AZ Maastricht, The Netherlands A. Exercise Design The exercise was developed and conducted by C. Kara-Zaïtri (University of Bradford and infact Ltd, UK) and H. ter Waarbeek (Public Health Service South Limburg and University of Maastricht) as part of the EMRIC+ project. B. Exercise Location The exercise was held at Kasteel Terworm, Heerlen. C. Exercise Date & Time Schedule The table top exercise was conducted on October 2, from 10 am till pm: Session 1: Introductory briefing Session 2: Exercise Scenario Phase 1 5

6 Session 3: Exercise Scenario Phase 2 Session 4: Evaluation within each group Session 5: Evaluation and feedback with all participants Session 6: Overall recommendations D. Format The Three Corner Point Exercise was conducted as a one-day table-top exercise (a time bound cross-border hepatitis A outbreak simulation) and started with an introductory briefing and explanation of the exercise. It was based on 14 timed Inserts (each containing weekly information) simulating the incident as it evolved in time. Injects included for example, new case information, alerts and media attention. There were three groups of participants representing the cross-border areas in the Netherlands, Germany and Belgium (Euregion Maas Rhine). Group discussions, national protocols and the Instruments developed during the course of the EMRIC+ project were used to make decisions and take actions. Participants had to work through the principles of local and cross-border response. Special attention was given to timely and adequate - cross-border communication and cooperation (eg joined outbreak investigation and establishing a cross-border outbreak management team). The exercise was guided by two Facilitators. Each of the three groups consisted of several s (communicable diseases specialists) and an Observer recording notes. Inserts were provided by the Facilitator. The Insert contained basic (case) information and allowed for adding questions (to gain more key information), answers (to questions from colleagues) or actions (informing other parties or response measures). Filled Inserts were returned to the Facilitator for checking actions undertaken, providing the required information, forwarding information to the other country when requested, and then handed back to the group. The Observer took notes of the group s discussion and key issues. During the exercise participants had to respond to questions from the media (represented by a journalist present) and decide on (cross-border) press releases. After the exercise an evaluation within each group was held. This feedback session was meant to discuss the EMRIC+ Instruments, to identify key issues and areas requiring improvement in cross-border infectious diseases control. The outcomes were used for evaluation and feedback with all participants. In the final session overall recommendations for cross-border cooperation and the implementation of the Instruments were made. 6

7 Crossborder Dashboard, Map: showing all cases (from the 1 st till the 14 th week of the outbreak) E. Photos 7

8 8

9 A. Positive experiences.. Individual Evaluation: Exercise aspects Strongly agree Agree Disagree Strongly disagree The exercise was well-organised The scenario and inserts generated useful 0 discussions The scenario generated important issues and identified lessons to be learned The aim of the exercise was achieved The venue and catering was appropriate Zeer geslaagde oefening. Mag zeker jaarlijks of halfjaarlijks georganiseerd worden. Very good exercise;would be good to organize every (half) year. Very good exercise! Unpredictable so very learnful Very well planned & organised. Future exchange of documents & contact details is import between country parties Thank you for the exercise! Heel veel geleerd vandaag. Learned a lot today. Keep on practising and know who your colleagues are in Germany and Belgium Try to build in some face to face contacts between the participating countries during the exercise Working agreement on lessons learned Crossborder facebook with photo/ /phone/skype Group Evaluation: Duitsland General observations Usefulness of EMRIC+ outputs Productive Arbeitsatmosphäre; gute Stimmung; Wahrnehmung dass Cross-border Zusammenarbeit notwendig & hilfreich ist --> complexity showed!; in the exercise the phone call with plenty of info was missing Productive working atmosphere; good vibes; conclusion that crossborder cooperation is vital and of use --> complexity shown! During the exercise using the phone for gathering information was missed. Practical: Schrift der Protokolle zum Teil schwer lesbar & Bedeutung der Kategorie Sprachbarriere --> Englisch nicht selbstverständlich (local agencies) Practical: written protocols sometimes hard to read & meaning of category. Language barrier --> English not obvious (local 9

10 agencies). Lessons to be learned Sprachbarriere gibt es: muss man berückzichtigen Flip chart Exchange of existing questionnaires. Documents used in each agency --> adapt (SOP depending on disease) There is a language barrier to consider. Flip chart. Exchange of existing questionnaires. Documents used in each agency --> adapt (SOP depending on disease). Recommendations vis-avis crossborder disease control Any other comments Crossborder Risk Alert Report --> Schulungen anbieten (Z.B. innerhalb des Gesundheitsamtes) EMRIC+ Treffen sollte Nachfolgung haben; Partner weiter treffen. Crossborder Risk Alert Report --> offer training (e.g. in company) EMRIC+ gatherings for partners should be continued Sehr gute Organisation --> Logistik war sehr Anspruchsvoll Very well organised. Logistics were very challenging België General observations Usefulness of EMRIC+ outputs Lessons to be learned Recommendations vis-avis crossborder disease control Prima, nuttige oefening. Voordeel van 'sparren' met meerderen. Minder blinde vlekken. We missen korte (telefoon)lijnen met buurlanden. Fine and useful exercise. Benefit of 'sparring' with more people. Fewer blind spots. We miss short (telephone) lines with neighbouring countries. Prima formulieren. Echter, wegens beperkte tijd in oefening té uitgebreid. Excellent forms. However, too elaborate because of lack of time during the exercise. Welke verschillen bestaan in richtlijnen buurlanden. Sneller specifieke informatie delen --> opschalen. Where do guidelines from neighbouring countries differ? Quicker sharing of specific information --> upscaling. Conference call/teamviewer/skype Up to date houden contactgegevens/collega's abroad Conference call/teamviewer/skype keep contact details updated/colleagues abroad Any other comments Nederland 10

11 General observations Usefulness of EMRIC+ outputs Lessons to be learned Leerzame oefening: samenwerking. Reports invullen niet vlekkeloos in te vullen Goed om de stappen 1 voor 1 door te lopen Grensoverschrijdend in je voorhoofd te hebben en niet in je achterhoofd Instructive exercise: cooperation. Reports hard to fill in flawlessly. Good to do it step by step. Active crossborder thinking; not something at the back of your mind. Risk alert reports zijn heel bruikbaar mits goed en tijdig ingevuld Risk alert reports are very useful if filled in correctly and timely. face to face contact, telefonisch contact gemist Alle casussen een nr. Data moeten digitaal opgeslagen kunnen worden face to face contact, contact by telephone was missed Numbering all cases It has to be possible to save data digital Recommendations vis-avis crossborder disease control Any other comments info moet vroegtijdig worden uitgevoerd soort oefeningen goed om crossborder te blijven denken Gebruik maken van digitale mogelijkheden Goede rapportage Vroegtijdig vorming crossborder- en managementteam Timely acting on information this kind of exercise good for crossborder thinking Make use of digital possibilities Good report Timely forming crossborder and management team Henriëtte en Chakib bedankt! Thanks Henriëtte and Chakib! General Observations: Excellent communication very important Sharing data and hypotheses invite others to think further Good exercise Useful exercise Not having direct phone contact is complicating factor Phone contact is sometimes better and faster One needs to visualize cases Nicely worked out exercise Good to have (the possibility of) cross-border spread in the front of your mind Using only cross-border templates is difficult, were not always completely filled in Learnt a lot, both on cooperation as on going through each (outbreak) step Teambuilding Very good: the exercise showed that cross-border cooperation can ease the infection s source detection and that cross-border communication is relevant Very good working atmosphere Interesting Informative 11

12 Activities and notifications embedded in cross-border cooperation Cross-border cooperation and management is complex By discussing with more (cross-border) colleagues less things will stay unnoticed Usefullness of EMRIC+ Instruments: Very useful in real situation (a bit too long for exercise purpose) Notification Template is okay, could possibly be shorter Template very useful for information exchange during outbreaks Template with CRAL can be a timely, easy and feasible way to alert each other across the border All Instruments proved to be very useful as background agreement to speak with one voice Template very useful communication tool, has to be filled in properly and timely though Provide good base and guide Very good and easy to use How to deal with different languages? English not always the best option for everybody. Everybody in own language? (Dutch/German) important issue during crises misunderstandings need to be avoided Need for telephone contact next to template Very good Instruments. Exercise time too limited to use them fully. Lessons learned Think bigger/euregional continuously Think about the reader when filling in information it has to be clear Contact foreign counterparts as early as possible Be very specific in your information to prevent misunderstanding Send Risk Alerts/Templates soon Don t miss anything take anamnestic information from each case (might give you an essential (cross-border) clue. Don t focus on one direction Need to know more about guidelines and protocols used by the others Need to know names and phone numbers of foreign colleagues Crossborder exercise makes 'crossboder' transmission/thinking part of regular workflow Being acquainted with the EP, CRAR, MDS and CRAL's makes it more easy to use in the future Missing face to face contact identifier on each case would be helpful Good communication with other countries is very important Good recording and reports is very important Need (to keep) the overview / complete picture Missed face-to-face contacts or telephone contact with crossborder colleagues Time-outs needed for aforementioned contacts Cases should all carry unique identifiers to ease communication! Adapt CRAP: fields CC+CR pretty useless, MMD dito! Digital data recording Use dashboard Contact person across the border should be known (including mobile phone number) Upscale early (outbreak management team) recommendations vis-à-vis crossborder disease control 12

13 standaard ontwikkelen wat betreft optekenen, zodat overzichtelijk geheel ontstaat van evt. Outbreak contact foreign counterparts as early as possible be very specific in your information to prevent misunderstanding constant up to date houden van contactgegevens zo snel mogelijk overleggen met crossborder collega's nogmaals oefenen, ook om elkaar te kennen en weten wie je kunt bellen/mailen over de grens voor overleg mogelijkheden conference call internationaal eens in de zoveel tijd overleg voor kennis vernemen algemeen werkinhoudelijk België en Duitsland to have more info on CRAR's further communication by telephone/skype/vis a vis is needed to fully understand each other relation to dashboard? Future exercises are needed to keep the crossborder Risk alert report wat aanpassen. Duidelijkere communicatie tussen landen duidelijke, beknopte maar volledige info doorgeven aan buurlanden. In de oefening bleek hierdoor soms info te missen See above: seek face-to-face/tel. Contacts early on Exchange information early on (e.g. case control study to be performed, questionnaires used etc.) Form outbreak management team early on Digital, real time exchange of data desirable! (enter data into common map, statistic epicurve early on Wahrnehmung/Definition der Risk Alert Level müssen übereinstimmen Projekt weiterführen, regelmässige Treffen zu vereinbaren Zu viele Informationen, dann knappe Zeit um genau zu arbeiten info moet vroegtijdig worden uitgevoerd. Soort oefeningen goed om crossboarder te blijven denken. Gebruik maken van digitale mogelijkheden. Goede rapportage. Vroegtijdig vorming corssboarder mangementteam. Crossborder risk alert report: Schulungen anbieten (Z.B. innerhalb des Gresundheitsamtes) EMRIC+-Treffen sollte Nachfolgung haben; Partner weiter treffen. conference call/teamviewer/skype up-to-date houden contactgegevens/collega's abroad Any other comments: Sehr gute Organisation: Logistik war sehr anspruchsvoll Grosser Lerneffekt. It would be a nice extra if you could follow the outbreak on the dashboard in all 3 countries Goede oefening en goed opgezet. Heel nuttig. Flow going-given the low incidence of crossborder transmission Henriëtte and Chakib: great job! Sehr gute Moderation 13

14 B. Key Issues identified and lessons learned 1. Euregional protocol with agreed Actions 2. Agreed Minimal Data Set (MDS) for Cases, Outbreaks and Exposure 3. Cross-border Risk Alert Levels (CRAL) 4. Cross-border Notification Template 5. Cross-border Dashboard C. Recommendations! Cross-border cooperation is essential but complex! The instruments developed are useful tools! Sharing data in realtime is key (eg cross-border dashboard)! Structured cooperation within a cross-border project should be continued! A cross-border exercise should be conducted yearly Appendix A: Summary of Recommendations! Cross-border cooperation is essential but complex! The instruments developed are useful tools! Sharing data in realtime is key (eg cross-border dashboard)! Structured cooperation within a cross-border project should be continued! A cross-border exercise should be conducted yearly! Appendix B: Abbreviations used Appendix C: Participant List Agency Country Delegate Role StädteRegion Aachen D V. Bochat 14

15 V. Claessen StädteRegion Aachen D C. Cormann M. Cransveld Secretary Observer/Recorder Toezicht Volksgezondheid VAC B A. Forier Gesundheitsamt Kreis Heinsberg D N. Franzke StädteRegion Aachen D H. Freund N. Gelissen Communication Specialist Press C. Gielkens Environmental Health Kreisverwaltung Euskirchen D J. Grumblat V. Hackert C. Hoebe GGD Limburg-Noord P. Jacobs In-Fact GB C. Kara-Zaïtri Facilitator M. van Kessel Infectious Diseases Nurse Leclercq Infectious Diseases Nurse Gesundheitsamt Kreis Heinsberg D F. Schopen 15

16 Toezicht Volksgezondheid B K. de Schrijver H. Sijstermans Secretary Observer/Recorder R. Sleijpen Public Health Manager Observer/Recorder C. Somers Infectious Diseases Nurse StädteRegion Aachen D Stalder Gesundheitsamt Kreis Heinsberg D G. Vossenkaul H. ter Waarbeek Facilitator Appendix D: Participant Evaluation Acknowledgements Helen Sijstermans, Public Health Service South Limburg Chris Hills, infact Ltd Marian Rademakers, project leader EMRIC+ 16

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