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					Script #1
Date and Time: Tuesday, June 22nd 4:00 pm

Time Allotted: 10 minutes

Events:
    Hennepin County has 11 cities with their own environmental health program for
      food, beverage and lodging (FBL) inspections. Some of these programs have
      only 1 to 3 employees; others have mare than 10 employees.

      The remaining 34 cities are covered by Hennepin County. FBL is a delegated
       program from the Minnesota Department of Health pursuant to powers granted
       under Minnesota Statutes Sections 145A.01-145A.1 and 375.51-375.55 and the
       Minnesota Rules Chapter 4626.

      Hennepin County operates under ordinance number 3 and cities have their own
       ordinances. Hennepin County Provides epidemiology services for all but 3 cities
       (Bloomington, Edina and Richfield).


      At 4:00 pm Saint Louis Park’s Environmental Health Department receives a one
       phone call from an individual wanting to file a complaint against Andy’s
       Restaurant.

      The individual placing the call reports that she and 2 of her friends ate at Andy’s
       Restaurant and all three are now experiencing vomiting, nausea, and stomach
       cramps.

Data Inject:
    Hennepin County map

Issues for Discussion:
     Initial Notification
     Process for responding to the phone call
Script #2
Date and Time: Wednesday, June 23rd 8:30 am


Time Allotted: 20 minutes

Events:
    At least one of Saint Louis Park’s Environmental Health Specialists has
      completed an inspection/investigation of Andy’s Restaurant and could not find
      any significant evidence that would suggest that Andy’s Restaurant is the cause of
      the illnesses reported the day before.

      Hennepin County’s Environmental Health Department receives one call from a
       citizen of the area reporting a total of five gastrointestinal type illnesses. All had
       lunch at the prestigious Michelle Larson’s Bistro.


      Brooklyn Park’s Environmental Health Department receives one phone call from
       a citizen of the area reporting a total of three gastrointestinal type illnesses after
       eating dinner the night before at Cheryl’s Chateau.

      Five phone calls are made to the City of Minnetonka’s Environmental Health
       Department reporting six individuals with stomach cramps, vomiting, and nausea
       after eating at Victor’s Vineyard.

      The City of Plymouth’s Environmental Health Department has received three
       calls reporting eight persons with stomach cramps, vomiting and nausea after
       eating brunch at Casa Del Erin.

Data Inject:
    Reporting Form

Issues for Discussion:
     Notification Procedures
     Investigation Procedures Form
Script #3
Date and Time: Wednesday, June 23rd 12:30 pm

Events:
    The first callers to Saint Louis Parks Environmental Health Department continue
      to call and want to know what is being done. Saint Louis Park sends the five
      individual stool kits.

      Hennepin County prepares for a conference call and establishes who to include.

      Brooklyn Park has notified the County Epidemiologist and Minnetonka and
       Plymouth have Notified MDH and the State Epidemiologist.

      No local agencies have been in contact with one another. The illness has yet to be
       identified and no restaurant has been implicated.

      One of the cases is a young child, age five. The parents brought the child to the
       Doctor and stool samples have been taken.

      A television reporter calls the City of Minneapolis complaining of diarrhea and
       stomach cramps. He says he is, “sick as a dog”. He also reports that several of
       his friends are having similar symptoms and he wants to know “What the hell is
       going on”!

      The City of Bloomington’s Environmental Health Department receives ten more
       calls from ill citizens.

      Saint Louis Park’s Environmental Health Department receives thirteen additional
       phone calls from ill citizens.

      Minneapolis’ Environmental Health Department receives 26 more complaint calls
       from citizens of the area, all are complaining of gastrointestinal type illness and
       symptoms.

Data Inject:
    Quick Conference Call

Issues of Discussion:
     Notification Procedures
     Investigative protocol
     Protocol for staff contacts
     Media for Hotline
Script #4
Date and Time: Thursday, June 24th 3:00 pm

Time Allotted: 30 minutes

Event:
    Hennepin County contacts the State Health Department to set up a hotline

      Epidemiologists at the County and State level are now aware of the situation after
       the conference call has been held.

      Environmental Health Specialists continue inspection of all suspected restaurants.

      The State Health Department is now using the media in order to promote the
       hotline to the public.

      Hundreds of calls are coming in to all of the Environmental Health agencies with
       reports of bloody stool, vomiting and nausea.

      Hospitals and clinics are seeing an elevated amount of gastrointestinal type illness
       than usual.

      The Mayor of Minneapolis has been briefed on the situation and is on alert for
       any new information.

      People Against Sprouts of America (PASA), has claimed responsibility for the
       contamination of alfalfa sprouts with salmonella.

Issues for Discussion:
     Case Definition
     Key message from MDH and Epi regarding antibiotics
     Message to the pubic
     Communication to medical facilities
     Communication within the cities
     Risk Communication messaging
Script 5

Date and Time: June 25th, 2 pm

Time Allotted:

      Case identification identified.
      Lab reports of the child confirmed it is shigella.
      Due to the data available it seems that more than one restaurant is involved.
      Message via MDH Health Alert Network about antibiotic treatment.
      City and County officials have been notified about numerous cases in their
       county.
      MDH has communicated to local level and local level to MDH.
      Triage and managing of worried well and symptomatics are being appropriately
       treated at hospitals and clinics.
      County and State EOC continue to communicate together.
      County and State Epi and Environmental Health agencies are now collaboration
       in this outbreak.
      Sanitarians are doing investigation of restaurants.
      The child still has blood in his stool but he is recovering.
      Laboratory results have come back positive.

Issues for Discussion:
    
Script 6

Date and Time: June 25th

Time Allotted: 50 minutes

      All environmental health agencies have completed inspections of restaurants.
      Epi data showed identity of shigella on shipped parsley that is not being
       distributed here any more.
      Sharing of results and discussion.

Issues for Discussion:
    
                             FACILITATOR QUESTIONS

Script #1: St. Louis Park: How will your environmental health agency respond to
this call? What is your initial notification process with this type of call?

Script #2: Ask each of the following agencies the same question as #1 with 2-3
minutes per answer: Hennepin County E.H., Brooklyn Park, Minnetonka, and
Plymouth.

         Ask about the data inject: Are you all using this foodborne illness
reporting form?

        Hennepin County Epi: Have you been contacted by these agencies that
        are receiving                       the foodborne illness calls?


Script #3: Ask each of the following agencies the same question as #1 with 2-3
minutes per answer: Bloomington, Minneapolis, Crystal, Golden Valley, Edina,
Richfield, Hopkins, and Wayzeta.

        (Cue if not mentioned): At what point is local environmental health
        contacting the MDH epi?

        Brooklyn Park: Where did you send your epi info? County or State?

        Hopkins & Brooklyn Center: How can your environmental health staff be
        contacted? Are they 24/7? If not, who replaces them on those days?

Script #4: What message are you giving to the public and where are you getting
the information from? (ask random agencies).

         To MDH Epi: Is that the correct answer? Are they going through the
         process correctly?

         WCCO calls Curt Fernandez and asks for a statement. What do you
         do? (Ask Mr. Fernandez)

         Who has contacted hospitals and doctors in regards to this issue?
         What are you telling them?

         What other stakeholders are being notified in your community (i.e. city
         council, mayor)

         Is there any reason to think that this is a bioterrorism event?
Script #5: Are the environmental health agency’s sanitarians sharing and
communicating information that they have found during their inspections?
Should they?

Script #6: Debrief: What did you learn today? Are there new goals and
objectives that could be developed after today? Could another tabletop take
place again in the future?
                     Hennepin County Human Services Department
         Environmental Health Tabletop Exercise

                                  June 24, 2004

                                Player Evaluation
   1. Please evaluate the extent to which this exercise met each of the
      stated objectives for the day.


Objectives                                  Did not Meet              Met Fully
Establish the flow of food borne illness       1     2       3       4     5
reports to and from the local
environmental health agencies, county
epidemiology and state epidemiology.

Identify the roles of the local               1         2        3   4     5
environmental health agencies, county
and state epidemiology during a
countywide investigation.

Identify and assess each agencies             1     2        3       4     5
responsibilities, capacity and ability to
respond to large complex outbreaks.

Examine what is in place for sharing           1     2       3       4      5
resources, as well as barriers, (who
seeks help from who and who
orchestrates sharing of resources).
Identify appropriate contacts within and       1        2        3    4      5
between agencies during an outbreak.
Identify Current communication                 1         2       3    4         5
strategies between agencies and
jurisdictions regarding disease
surveillance information to be shared
for an effective response.



Comments:
2. Please evaluate the exercise format and facilities.


Statement                                Disagree                    Agree

The exercise format worked well.         1       2       3      4          5


The exercise format helped me to
assess preparedness for my areas of      1          2    3      4            5
responsibility.


The meeting facility and services were   1       2       3       4               5
adequate.



Comments:

   3. What were the main lessons you learned from the exercise?




   4. Did you identify any gaps in existing response plans or any topics
      needing additional attention or discussion? If so, in what areas?




   5. Are there other steps necessary to enhance preparedness for a
      response to a food borne outbreak? Be as specific as possible.




   6. How do you think the exercise could have been improved?
                   Hennepin County Human Services Department
       Environmental Health Tabletop Exercise

Design Team:
Deidre Qual

Michelle Larson

Victor Sabandeja

Cheryl Petersen-Kroeber

Marilyn Cluka

Andy Gray

Erin Schroeder

Susan Palchick
                   Hennepin County Human Services Department
                     Environmental Health Tabletop Exercise


Participants:
Local Environmental Health Directors
      Bloomington
      Richfield
      Edina
      Minneapolis (Plus 2 inspectors)
      Brooklyn Park
      Crystal
      Golden Valley
      St. Louis Park/Wayzata
      Minnetonka
      Hopkins
      Hennepin County (Plus 2 inspectors)

MDH Epidemiology
     2 Epidemiologists
     1 manager

Hennepin County Epidemiology
     2 Epidemiologists

Hennepin County Emergency Preparedness
     Supervisor

Hennepin County
     Public Information Officer

MDH Emergency Preparedness
     Regional Consultant (Observer)

MDH Environmental Health
     Manager (Observer)
                    Hennepin County Human Services Department
                      Environmental Health Tabletop Exercise

                                        Goal

To access current communication barriers during a county-wide food borne
illness outbreak investigation between Local Environmental Health Departments,
MDH Epidemiology, and Hennepin County Epidemiology.


                                 Objectives

      Establish the flow of food borne illness reports to and from the local
       environmental health agencies, county epidemiology and state
       epidemiology.

      Identify the roles of the local environmental health agencies, county and
       state epidemiology during a countywide investigation.

      Identify and assess each agencies responsibilities, capacity and ability to
       respond to large complex outbreaks.

      Examine what is in place for sharing resources, as well as barriers, (who
       seeks help from who and who orchestrates sharing of resources).

      Identify appropriate contacts within and between agencies during an
       outbreak.

      Identify Current communication strategies between agencies and
       jurisdictions regarding disease surveillance information to be shared for an
       effective response.
                     Hennepin County Human Services Department
                       Environmental Health Tabletop Exercise

                Script                        Key Issues               Data Injects             Time Allotted
Script #1:                              Initial notification        Hennepin County     10 minutes
Telephone Call received by St           How to respond to the        Map                 (8:30 – 8:40)
Louis Park Environmental Health;         call
One person reporting 3 unrelated
people sick.
Script #2:                              Notification process,       Correct form        20 minutes
Telephone call 1 call from              Investigation process                            (8:40 – 9:00)
Brooklyn Park, 3 people ill. 5          Forms
Calls to Minnetonka, 6 people ill.      Stool kits out
Plymouth 3 calls, 8 ill people.         When to notify
Hennepin County EH 1 call                Epi/Which Epi
reporting numerous cases.
Script #3:                              Bloomington 10 calls        Conference call,    30 minutes
Telephone call from news                St Louis Park 13 calls       county, state epi   (9:00 – 9:30)
reporter/ ill and knows of several      Mpls 26 calls                and other hot
others ill.                             Notification                 players
                                        Procedures
                                        Investigative process
                                        Protocol for staff
                                         contact
                                        Use media to call
                                         hotline
                                        How big is this?
Script #4:                              Case definition             Epi curve           30 minutes
Hundreds of calls…Management            Key messages from                                (9:45 – 10:15)
of cases                                 MDH and EPI re:
                                         antibiotics
                                        Local communication
                                        Media calls to EH
                                        Message from Co epi
                                         to medical partners
                                        Communication within
                                         the city
Script # 5:                             Results of lab                                   10 minutes
Investigation of food facilities                                                          (10:15 – 10:25)
Script # 6: Debriefing and              Long range table top                              50 minutes
Summary                                  exercises                                        (10:25 – 11:15)
                                        Impact of event on
                                         Hennepin County
                                        Information flow
                                        Moving forward from
                                         here!
            Hennepin County Human Services Department
          Environmental Health Tabletop

                            Agenda


8:00 AM     Participant and Observer Registration

8:15 AM     Opening Remarks and Introduction to the Exercise
            (Michelle Larson)

8:30 AM     Exercise Scripts and Discussion (Michelle Larson and
            Exercise Participants)

               Script #1              8:30 - 8:40 (10 minutes)
               Script #2              8:40 - 9:00 (20 minutes)
               Script #3              9:00 - 9:30 (30 minutes)

9:30        BREAK

9:45        Exercise Scripts and Discussion (Michelle Larson and
            Exercise Participants)
             Script #4              9:45 - 10:05 (30 minutes)
             Script #5              10:05 – 10:25 (10 minutes)

10:25       Summary and Debriefing

11:15       ADJOURN
                                Cities Regulated by Hennepin County Environmental Health
                                             for Food, Beverage, and Lodging




                                                                      Rog ers
                                                                                               Dayton
                                                       Hassan
                                                                                                                   Cha mplin


                                      Han over

                                                                                                                                  Broo klyn Park


                                                                                                                       Osse o
                                                      Corcoran                             Ma ple G rove
                                 Gre enfie ld
Rockford

                                                                                                                                          Broo klyn Ce nter


                                                    Loretto
                                                                                                                                Crystal
                                                                                                                        New
                                                                                               Plymou th                Hop e
                                                           Me din a
                                                                                                                                         Rob bin sd ale
    In dep end ence                                                                                                                                                    St. An thon y

                                Ma ple Plain                                                               Me dicine
                                                                                                           Lake

                                                                                                                             Gold en Valle y
                                                          Lon g Lake
                                                                                W ayzata

                                                      Oro no
                                                                                                Min ne to nka
                                                          Min ne to nka          W oo dlan d
                                                            Bea ch                                                      St. Lou is Park
          Min ne trista                   Sp rin g Park                          Dee ph aven
                                    Mo un d
                                                                                                                  Hop kins
                                                    Tonka Bay
                                                                          Gre enw oo d
                                                                                                                                                                  Min ne apo lis
St. Bo nifaciu s
                                                Sh orewo od    Excelsior


                                                                                                                                Ed ina
                                                                                                                                                                         Fort Sn elling /
                                                                           Cha nh asse n                                                              Richfield         Mp ls Int'l Airpo rt


                           Cities regulated by
                           Hennepin County
                                                                                                                                Blo omin gton
                           Environmental Health                                            Ed en Prairie




                                                                                                                                                                                               N
So urce : H enn epin Co unty C ommu nity H ealth D epa rtme nt, D ecemb er 2 000                                                     2            0           2             4 Miles
Prod uced by: H enn epin Co unty C ommu nity H ealth D epa rtme nt, D ecemb er 2 000
re g u la te d ci tie s.a p r
Background and Facts on shigella gastroenteritis

Symptoms-

      Diarrhea (which may contain traces of pus, mucus or blood)
      Fever
      Abdominal cramps
      Nausea
      Vomiting
      Dizziness when standing up.

Possible complications-
Young children are more susceptible to complications, which may include:

      Febrile seizures caused by fever
      Dehydration
      Headache
      Lethargy
      Stiff neck
      Confusion.

Transmission-
Shigella bacteria are excreted in feces. If an infected person doesn't wash
their hands after going to the toilet, the bacteria can be spread by touching
objects and surfaces which will be touched by other people, or food which
may be eaten by other people. It is possible to get shigella gastroenteritis
from drinking water that is contaminated with human feces containing
Shigella bacteria.

Lingering risk of transmission-
The symptoms of shigella gastroenteritis may clear up after a week or so, but
the person can have Shigella bacteria in their feces for at least four weeks
after the symptoms stop. Occasionally, a person may excrete the bacteria for
months after the symptoms have stopped.

Treatment options-

      Appropriate antibiotics to kill the bacteria within a matter of days.
      Plenty of fluids.
      In severe cases, intravenous fluids may be needed.
      Eating solid foods should be encouraged.
      Avoid anti-vomiting or anti-diarrhea drugs unless prescribed or
       recommended by your doctor.
                    Shigellosis, 2002
Introduction to Annual Summary of Communicable
Diseases, 2002
List of Reportable Diseases, 2002
Number of Cases of Selected Reportable Diseases, 2002
During 2002, 222 culture-confirmed cases of Shigella
infection (4.5 per 100,000 population) were reported (Figure
2). This represents a 55% decrease from the 493 cases
reported in 2001, a 75% decrease from the 904 cases
reported in 2000 (the largest annual number of cases ever
reported in Minnesota), and a 33% decrease from the
median number of cases reported annually from 1997 to
2001 (median, 331 cases; range, 138 to 904).
In 2002, Shigella sonnei accounted for 179 (81%) cases, S.
flexneri for 32 (14%), S. boydii for two (1%), and S.
dysenteriae for one (<1%); eight isolates were not
serotyped. Casepatients ranged in age from 3 months to 77
years (median, 10 years). Fortyeight percent of case-
patients were less than 10 years of age; children less than 5
years of age accounted for 26% of cases. Thirty-two (14%)
casepatients were hospitalized. Seventysix percent of case-
patients resided in the seven-county Twin Cities
metropolitan area, with 45% of all casepatients residing in
Hennepin County.
Six outbreaks of shigellosis were identified in 2002; all were
person-toperson outbreaks due to S. sonnei. These
outbreaks resulted in at least 75 illnesses, including 36
culture-confirmed cases (representing 20% of all reported
S. sonnei cases). Four of the outbreaks occurred in child
daycare settings, and two occurred in elementary schools.
In addition, two cultureconfirmed S. sonnei cases reported
in 2002 were part of a S. sonnei outbreak in an elementary
school that began in December 2001.
Every tenth Shigella isolate received at MDH was tested for
antimicrobial resistance, but only one isolate from each
outbreak was included. Twenty isolates were tested in
2002; 90% of isolates were resistant to ampicillin, and 20%
were resistant to trimethoprim-sulfamethoxazole. Twenty
percent of isolates tested were resistant to both ampicillin
and trimethoprim-sulfamethoxazole.
If you have questions or comments about this page, contact
idepcweb@health.state.mn.us or call 612-676-5414 (TTY:
612-676-5653) for the MDH Infectious Disease
Epidemiology, Prevention and Control Division.


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Updated Thursday, 20-May-04 14:44:08
                         Shigellosis




Clinical        Watery or bloody diarrhea, abdominal pain, fever, and
Features        malaise.
Etiologic       Four species of Shigella: boydii, dysenteriae, flexneri, and
Agent           sonnei.
Incidence       Approximately 14,000 laboratory confirmed cases of
                shigellosis and an estimated 448,240 total cases (85% due
                to S. sonnei) occur in the United States each year. In the
                developing world, S.flexneri predominates. Epidemics of S.
                dysenteriae type 1 have occurred in Africa and Central
                America with case fatality rates of 5-15%.
Sequelae        Reiter's syndrome is a late complication of S. flexneri
                infection, especially in persons with the genetic marker
                HLA-B27. Hemolytic-uremic syndrome can occur after S.
                dysenteriae type 1 infection. Convulsions may occur in
                children; the mechanism may be related to a rapid rate of
                temperature elevation or metabolic alterations.
Transmission A small inoculum (10 to 200 organisms) is sufficient to
             cause infection. As a result, spread can easily occur by the
             fecal-oral route and occurs in areas where hygiene is poor.
             Epidemics may be foodborne or waterborne. Shigella can
             also be transmitted bu flies.
Risk Groups     In the United States, groups at increased risk of shigellosis
                include children in child-care centers and persons in
                custodial institutions, where personal hygiene is difficult to
                maintain; Native Americans; orthodox Jews; international
                travelers; men who have sex with men; and those in homes
                with inadequate water for handwashing.
Surveillance    All reported cases are laboratory-confirmed in states or at
                CDC. Shigellosis is a notifiable infectious disease.
 Trends              Decreasing incidence in cases since 1995; characteristically,
                     S. sonnei causes large periodic outbreaks.
 Challenges          Increasing resistance to available antimicrobial agents
                     among isolates acquired domestically and abroad; absence
                     of effective vaccines; modifying handwashing behavior to
                     control prolonged community-wide outbreaks; identifying
                     targeted prevention measures in high-risk groups (e.g.,
                     Native Americans, Orthodox Jews, men who have sex with
                     men, and children who attend daycare).
 Opportunities A major initiative to strengthen laboratory, epidemiologic,
               and public health capacity to detect and respond to epidemic
               S.dysenteriae type 1 in southern Africa could be duplicated
               in other regions at risk. Partnerships with local health
               departments and communities may lead to investigations of
               transmission and new prevention materials. Subtyping of S.
               sonnei by pulsed field gel electrophoresis can improve
               outbreak detection and control.

                                                                        December 2003




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               This page last reviewed February 12, 2004

                     Centers for Disease Control and Prevention
                       National Center for Infectious Diseases
                      Division of Bacterial and Mycotic Diseases

				
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