After Action Report / Improvement Plan

After Action Report Improvement Plan Operation POD Squad Point of Dispensing Functional Exercise June 18, 2013 Southeast Ohio Public Health Region Consolidated 1 Page

ADMINISTRATIVE HANDLING INSTRUCTIONS 1. The title of this document is The "Operation POD Squad - A Point of Dispensing Functional Exercise - Southeast Ohio" After Action Report. 2. The information gathered in this AAR/IP is classified as For Official Use Only (FOUO) and should be handled as sensitive information not to be disclosed. This document should be safeguarded, handled, transmitted, and stored in accordance with appropriate security directives. 3. At a minimum, the attached materials will be disseminated only on a need-to-know basis and when unattended, will be stored in a locked container or area offering sufficient protection against theft, compromise, inadvertent access, and unauthorized disclosure. 4. Points of Contact: Health Department: Betty King Southeast Ohio Public Health Region (Office) 749-374-2782 # 1013 (E-Mail) bking@washco-ohhealth.org Exercise Director: Chris Floyd Disaster Resistant Communities Group LLC (Office) 850-241-3565 (E-Mail) chrisfloyd@drc-group.com 2 Page

CONTENTS ADMINISTRATIVE HANDLING INSTRUCTIONS... 2 CONTENTS... 3 EXECUTIVE SUMMARY... 4 SECTION 1: EXERCISE OVERVIEW... 5 Exercise Details... 5 Participant Information... 5 SECTION 2: EXERCISE DESIGN SUMMARY... 7 Exercise Purpose and Design... 7 Exercise Objectives, Capabilities and Activities... 7 Scenario Summary... 7 SECTION 3: ANALYSIS OF CAPABILITIES... 9 SECTION 4: CONCLUSION... 34 APPENDIX A: IMPROVEMENT PLAN... 35 APPENDIX B: PARTICIPANT FEEDBACK (3 THUMBS UP 3 THUMBS DOWN)... 36 APPENDIX C: ACRONYMS... 55 3 Page

EXECUTIVE SUMMARY Operation POD Squad - A Point of Dispensing Functional Exercise - Southeast Ohio was designed and facilitated to assess the capabilities of the municipal public health agencies within the Essex Regional Health Commissions jurisdiction to effectively manage Point of Dispensing operations in the event of an influenza pandemic. The purpose of this report is to analyze exercise results, identify strengths to be maintained and built upon, identify potential areas for further improvement, and support development of corrective actions. Incorporated in Section 3: Analysis of Capabilities of this After Action Report is a comprehensive listing of each Target Capability with its associated Major Strengths, Primary Areas for Improvement and Improvement 4 Page

Exercise Details SECTION 1: EXERCISE OVERVIEW Exercise Name: Type of Exercise: Operation POD Squad - A Point of Dispensing Functional Exercise - Southeast Ohio Functional Exercise Start Date: June 18, 2013 Duration: Location: Sponsor: Three Hours Local County Health Departments Southeast Ohio Public Health Region Program: The exercise was conducted as part of the region s public health preparedness program. Purpose: The purpose of the exercise was to assess the capabilities of the region s municipal public health agencies to effectively manage Point of Dispensing operations in the event of an influenza pandemic. Mission: To provide the staff and management of the region s municipal public health agencies with a stronger understanding of the various roles and responsibilities associated with operating a Point of Dispensing. Scenario Type: Influenza Pandemic Participant Information Participant Location Belmont County Coshocton County Harrison County Jefferson County Morgan County 5 Page

Noble County Perry County Number of Participants 83 6 Page

SECTION 2: EXERCISE DESIGN SUMMARY Exercise Purpose and Design The purpose of the exercise was to assess the capabilities of the region s municipal public health agencies to effectively manage Point of Dispensing operations in the event of an influenza pandemic. Exercise Objectives, Capabilities and Activities Capabilities-based planning allows for the exercise planning team to develop exercise objectives and observe exercise outcomes through a framework of specific action items that were derived from the Target Capabilities List (TCL). The capabilities listed below form the foundation for the organization of all objectives and observations in this exercise. Additionally, each capability is linked to several corresponding activities and tasks to provide additional detail. Based upon the identified exercise objectives below, the exercise planning team decided to demonstrate the following capabilities during this exercise: Medical Countermeasure Dispensing / Mass Prophylaxis Activity # 1 Target Capability Direct Medical Countermeasure Dispensing / Mass Prophylaxis Tactical Operations # 2 Activate Medical Countermeasure Dispensing / Mass Prophylaxis # 3 Conduct Medical Countermeasure Dispensing # 4 Adverse Events Monitoring # 5 Demobilize Scenario Summary Day 1 An outbreak of unusually severe respiratory illness has been identified in a small village in southern China. At least 25 cases have occurred affecting all age groups; 20 patients have required hospitalization, five of whom have died to date. Surveillance in surrounding areas was increased resulting in new cases being identified throughout the province. Viral cultures collected from several of the initial patients are positive for type A influenza virus. 7 Page

Day 6 Samples of the virus were sent to the World Health Organization (WHO) and the Centers for Disease Control and Prevention (CDC) for further characterization. The Centers for Disease Control and Prevention (CDC) determines that the samples are type A H7N3, a subtype never before found in humans. Day 12 The findings from the Centers for Disease Control and Prevention (CDC) have been transmitted back to the Ministry of Health in China and throughout the World Health Organization s (WHO) network. The Centers for Disease Control and Prevention (CDC), in collaboration with the World Health Organization (WHO), has dispatched a team of epidemiologists and laboratory personnel to further evaluate the outbreak and disseminates a Health Alert Network advisory notifying clinicians and health departments in the United States to be on the alert for patients with severe respiratory illness and a history of travel to the region of Asia where the human cases occurred. Samples of the H7N3 influenza virus are sent to the World Health Organization (WHO) and the United States Food and Drug Administration (FDA), so that work can begin to produce a reference strain for vaccine production. 8 Page

SECTION 3: ANALYSIS OF CAPABILITIES Medical Countermeasure Dispensing / Mass Prophylaxis Performance Target Capability Activity # 1: Direct Medical Countermeasure Dispensing / Mass Prophylaxis Tactical Operations Associated Critical Tasks Task # 1.1: Coordinate distribution / administration of medical countermeasure / mass prophylaxis. Staff was knowledgeable. Routine exercises and meetings have made the process of dispensing / mass prophylaxis routine. Increased support and monetary contributions from Ohio Department of Health. Perry County Everyone knew where to find the information and had practiced these during the real world drive in flu clinic each year. Keep the latest information posted to the shared drive. Morgan County HAN alert handled properly. Everyone went to their appropriate plan for the information they needed for their area of expertise. Consider the possibility that health department and partner organizations have personnel that are sick. Staff had good discussion over countermeasure operations. 9 Page

Weak Staff needs to gain confidence in themselves - they know what needs done, sometimes they seem hesitant in speaking up. Work on team-playing skills and don't look to one or two individuals for answers. Staff entered EOP but decided NOT to establish ICS once the state declared an impending emergency and declared that the health department get ready. Staff continued to monitor and "talk" about ICS structure and who could be assigned where. There was no discussion of training ICS members, nor any thought at this point to the numbers needed to open a POD. Plans were being made to set up a POD, but without any ICS structure in place. Staff needs further training and an understanding of what the Emergency Operations Plan and the ICS structure does, and "when" and "why" it should be activated. Staff have all been assigned roles in the Emergency Plans, but many where unsure of what their roles were, or what they were to do. A DOC was never established throughout the entire exercise. Tactical communications were tested with the RCC, but there was little emphasis put on communications in general. A few things were found missing in the Plans. RSVP volunteers and the phone number to reach them was not listed, Jeff Lauer (EMA director) was missing a 24/7 number. Belmont County The participants were familiar with where to find the necessary information and knew the process / procedures that are established for the health department response. Additional subject matter / area specialists would have help in things moving quicker and more detailed discussions of issues and resolutions. Coshocton County Existing plans and past experience cover many aspects of the task of distribution and mass treatment / prophylaxis. 10 Page

Noble County ICS was established early during exercise play and executed well. JIT training has been utilized and practiced several times during real world events in this jurisdiction. Jefferson County Staff demonstrated a strong countermeasure distribution plan that is ready for rapid implementation. Task # 1.2: Coordinate public information regarding point of dispensing (POD) locations. PIOs worked with the right team to gather and disseminate important data at the RIGHT time. Continue to have PIO training for the State of Ohio via the Ohio Department of Health. Perry County PIO's were trained and had consistent messages. Always plan and practice. Morgan County They opened a JIC with the EMA and partners early during the incident. They posted to the health department's website, Facebook Account, and are establishing a Twitter Account. They would use the county's Everbridge System to send out notifications to the citizens of. 11 Page

They established a health department Hotline to answer questions. Weak Back-up PIO may need to be the primary PIO as the person listed as primary PIO often finds themselves the Incident Commander. During a large event the PIO and Incident Commander will not be able to be the same individual. Look at the ICS structure and consider people / position changes. If changes are made - train staff appropriately on new roles and responsibilities. Staff contacted RCC for an overarching message to send out to the public. RCC instructed the health department to utilize template in ANNEX B1. There were conversations about posting on web site and using Social Media, yet template was not pulled or looked at. Conversations quickly moved to finding a POD facility since primary contact person was unable to be reached by business phone or 24/7 number. The backup person for that facility was never contacted. The first alternate facility was reached and confirmed that we could take possession of facility within an hour. There was no investigation of whether we currently held an MOU with that facility, or a POD notebook for that facility was not discussed. Staff was very unsure about setting up the POD structure and that ate up a lot of time. Plans need to be clearer on our primary and secondary locations for PODS. The alternatives listed in the plans need to be removed, or made clear that we DO NOT hold MOU's with those facilities. It was fantastic that the staff was able to get control of a facility within the hour, but we hold no MOU with that facility, no security check, and no POD notebook. Staff needs to be aware of what current MOU's we have and where to find POD notebooks when needed. 12 Page

Belmont County The staff was very knowledgeable of PIO plans and where to find release templates that can be used for the media and public. They were a little unsure of if they should have a JIC or not. Coshocton County Knowledgeable PIO and Information plans and procedures. Noble County They will utilize a website, press releases through traditional media outlets and Facebook. Coordinate newer types of social media with partner organizations. Jefferson County Staff was proactive with a seasoned PIO and pre-scripted messages. Performance Target Capability Activity # 2: Activate Medical Countermeasure Dispensing / Mass Prophylaxis Associated Critical Tasks Task # 2.1: Ensure medical countermeasure dispensing / mass prophylaxis site operations are established in accordance with Memoranda of Agreement (MOAs) / Memoranda of Understanding (MOUs). Plans are reviewed / revised annually. MOUs are signed at this time also. 13 Page

Perry County MOU's are in place. Make sure all MOU's are current. Morgan County Resources identified immediately and contacted. All predestinated sites have MOU's in place with all except the fairgrounds were reviewed in 2012. The fairgrounds were last reviewed in 2008. Contacts numbers are located in POD notebooks. May consider using school buildings as POD Sites. Weak POD Manager / Operations Chief needs to become more familiar and comfortable with their multiple roles and responsibilities during POD operations. Review All-Hazards Response Plan Annexes on a more regular basis with this individual and others. Gained access to POD facility rather quickly and successfully. Once the POD facility was established staff entered ICS structure. A little confusion of assigning roles within the structure with personnel, particularly in the medical area. How and when to order SNS supplies was never established and at some point, staff just assumed they were on their way. Entered into phase on of plan by establishing a Closed POD for staff and volunteers. Moved on the Phase 2 to treat first responders. This Closed POD was established in the health department. I am unsure of the knowledge of staff about "how" and "when" to order SNS supplies. I believe the assumption was, if we are in an emergency situation, state automatically sends "push packs". 14 Page

Making sure local resources are depleted and how we would do that was very fuzzy. We were opening POD in a facility without an MOU. We also need to have clear guidelines in place as to who is considered "family" that will be treated in Phase 1. Belmont County Staff was familiar with POD site MOU's as well as partner MOU's for the operation and the site operations for those locations. Coshocton County MOAs / MOUs established at three separate locations. Update / renew MOUs and MOAs to remain current and ensure that location or facilities are still usable. Research other possible locations for PODs to ensure that all are not within one geographical area that could be inaccessible during an emergency situation. Noble County Plans both State and Local are well developed. Jefferson County Specific MOU s were not reviewed as part of the exercise, but were in place and ready to be implemented. Continue with past practices. Task # 2.2: Assemble needed supplies and equipment for POD operations including materials to prepare oral suspension. We can always use more equipment but we manage to string together the necessary equipment via the mass flu exercises that we perform annually we are able to use and transport necessary equipment. 15 Page

Increased funding and technology support from Ohio Department of Health Perry County Oral suspensions were not talked about. Morgan County The health department has a trailer that contains non-medical supplies to setup PODs at three sites. It also contains five mobile nurse stations. Logistics branch will contact local vendors for additional supplies. The primary POD location is also our daily DOC. Staff is very aware of what is currently available on site. Review procedures with Logistics Chief on how to request supplies through the EOC once the local resources are becoming depleted. Staff utilized the supply checklist in the plans very well. Staff seemed well aware of supplies needed and where to get them. One goal would be to have all administrative supplies needed for POD in a "Go Kit", so that when a POD needed to be established, time is not wasted on gathering up small items. At this point, the NAPH form should already be accessible for the public to fill out and I don't think that was thought about or discussed at any time during the exercise. Belmont County 16 Page

Staff was familiar with the supplies and equipment needed to prepare oral suspensions. Were unsure it adequate supplies and equipment could be obtained in a large disaster if it is not provided with SNS shipment. Coshocton County Readily available supplies exist to begin POD operations. Inventory existing supplies to determine what is currently available and determine if there are any gaps to be filled. Noble County Checklists have been pre-developed to ensure the items needed are taken to the site. Jefferson County Staff demonstrated the ability to ready necessary supplies. Task # 2.3: Prepare informative materials for POD staff, patients and media. Agencies are able to find literature and information available to distribute to the public. Paper fact sheets printed from our state department for each local to disseminate would help! Lack of toner and printing paper may be a challenge for a large county. Perry County Prepared information materials were readily available. Look to CDC for conformation of materials. Morgan County Lack of local media. 17 Page

The PIO has excellent background dealing with the media and has a backup person in place. The PIO established a Joint Information Center early in the process at the EMA Office. They used multiple media outlets (Facebook, web site, etc.) and they also use their Everbridge Reverse 911 System to notify the public. A hotline was advertised. Weak Backup PIO has a strong knowledge of education materials (universal precautions) that will need to be prepared. Individuals also have a take-charge attitude to get tasks performed quickly and efficiently. Further development of pre-scripted messages would help alleviate any time-lag during an event. The templates for the PIO were not found in the B1 Annex of the plan the staff had available. Staff was relying on RCC to give them the overarching message they needed. Staff did not further investigate where they could find these templates. It was decided to use web site, social media and press releases to inform public about the epidemic and about the POD. Staff did not get in depth about "What" information they were going to be made available and still not talk of NAPH forms. In the plans, it is recommended that the name, address and physical history (NAPH) form be made available to fill out and print at home. Since head of household can pick up oral medication for up to 20 people, most of this paperwork should be done prior to showing up at POD. We need to make sure this is clear and ready to launch if need arises. 18 Page

Belmont County Templates were prepared and are ready for use. They also have a process / policy to prepare and approve additional informative materials as needed. In addition to MOU's with printing companies as well as local and regional partners to prepare materials. Coshocton County Existing plans cover public information as well as distribution of information to staff. Noble County Some information has been pre-developed additional materials will need development dependent upon specifics. A method to establish additional social media outlets directly from the health community with information is recommended. Jefferson County Task # 2.4: Provide internal and external security for POD sites. Our locations are easy to secure and have easy traffic flow patterns. We would like to think that in a real world situation that the security would be there but are sheriff's department is small and may have other responsibilities during a crisis. Perry County relationship with law enforcement. 19 Page

Morgan County Due to limited law enforcement there would be a need for State Highway Patrol and National Guard to assist with site security. Local police academies used to assist with traffic control. Pick sites that require a smaller amount of security. Weak Safety Officer will be working with local law enforcement individuals for provision of services. Additional security will be needed - look for ways to bolster this element. Staff was clear about who within the health department was in charge of security. They decided to call the sheriff to obtain deputies to help in the POD. The security checklist was pulled from our Primary Facility POD notebook and was being used to secure alternate site. Plans were not referenced as to security. This is a weak area and needs to be addressed. If deputies are busy and cannot be accessed, then what? Belmont County They were very familiar with local law enforcement agencies, local private security firms, as well as their duties and abilities. They also knew that in a disaster they may not be available or be in numbers adequate to do the job effectively. State officials work with state law enforcement agencies to work / develop policies / plans to encourage local law enforcement to remedy these issues. Coshocton County 20 Page

Security would be provided by local sheriff s office as well as volunteer personnel. Unsure Noble County Security partners have been identified but manpower is likely inadequate. Jefferson County County sheriff was specifically utilized in the exercise as the principle security agent. Performance Target Capability Activity # 3: Conduct Medical Countermeasure Dispensing Associated Critical Tasks Task # 3.1: Implement dispensing plan in accordance with state / local plans. Routine exercise of these scenarios has made this department strong and familiar with this practice. Perry County Plans were compliant with EMA and other local plans. Post updates to shared folder at LHD. Morgan County 21 Page

Everyone went immediately to local and state plans before backing decisions on how to proceed. Plan is the same one that is used for general influenza clinics - just on a larger scale. Staff is familiar with current operations. Non-Existent Other than the setup of the POD, and referencing that there would be "Forms", staff did not go deep into the actually dispensing of the medications and how that would "look" and what precautions needed to be followed. Part of this was the lack of medical representation at the exercise. There was no medical representation at the exercise, so this part was easily skipped. I would recommend that a separate training and review be done with the Director of Nursing as to the actual dispensing and training on the plans. Belmont County Participants were familiar with dispensing plans as well as ICS for operations of the facilities. Main concern was with staffing as exercise proceeded and availability was greatly diminished. Coshocton County Ohio Department of Health and existing plans outline procedures for dispensing. Noble County Staff is well trained and has had significant experience in running vaccination centers. 22 Page

Jefferson County Mass Prophylaxis plan is built to the regional model from guidelines specified by the Ohio Department of Health. Task # 3.2: Maintain a system for inventory management to ensure availability of critical medical countermeasure / prophylaxis medicines and medical supplies. Systems and measures are in place to monitor inventory. Increase technological support from Ohio Department of Health. Perry County Inventory systems were adequate. Morgan County Logistics and medical supply staff were clearly identified and they conversed as to what supplies are on hand and what is needed. Non-Existent Local inventory plan / policy is included in Annex H. Impact SIIS is utilized as well as an in house spreadsheet system. Train additional staff on inventory procedures using the above methods. 23 Page

Not touched on at all. As stated before, there was no medical representation at the exercise and some of these details were skipped. This may have to be a separate training with the staff. Make sure everyone knows where to find the guidelines and forms in the plan. Belmont County EXEL and HDIS were the primary inventory management programs utilized for inventory management. There was concern if there was power disruption. Additional backup options for inventory management, plans for paper tracking options. Coshocton County Existing plans outline procedures for inventory of critical medications and supplies. Noble County Utilize spreadsheets to forecast. No database. Jefferson County Inventory management injects were adequately addressed in the exercise. Task # 3.3: Ensure availability and distribution of pre-printed drug information sheets. Paper fact sheets printed from our state department for each local to disseminate would help! Lack of toner and printing paper may be a challenge for a large county 24 Page

Perry County CDC provided much information for drug information. Plans had adequate information on drug information sheets. Morgan County The PIO advised that information was provided in English and interpreters were brought in for Non-English speaking individuals. Printed material would be processed as it becomes available from the CDC and Ohio Department of Health. Weak Staff entered long conversation about how we would handle all the phone calls from the public even though they would be given a 1-800 number or "hotline" from the state to gain information. Staff concerned that they will be overwhelmed by phone calls. Some discussion about the capabilities of our phone system at the health department. Everyone was clear that the information would be handed out at the POD and listed on our web site. Staff needs to think about and know ahead of time how they will handle phone calls during emergency and how they will set up phone system to direct callers to appropriate people and or hotlines. Belmont County Health department maintains printing capabilities, has local and 25 Page

regional MOU's, and private corporation MOU's. Coshocton County Ohio Department of Health provided as well as manufacturer supplied. Noble County Action line is printed on pamphlets and gives the local health department information. Jefferson County Jefferson County Health Department plans accommodate the need for mass printing and information distribution. Performance Target Capability Activity # 4: Adverse Events Monitoring Associated Critical Tasks Task # 4.1: Track outcomes and adverse events following mass distribution of medical countermeasure / prophylaxis. EPI's and the tracking system have enabled us to track better than ever. Perry County Sheets were passed out to all persons that were given drugs and asking for anyone who has a reaction to contact LHD. Sheets were available. 26 Page

Morgan County Weak Promoted individuals that had adverse effects to contact their primary care physician or go to the hospital. Consider follow up by health department personnel for any future similar type event. Reactions to a particular medication may need more attention. Adverse events are tracked utilizing Impact SIIS. This area needs to be improved upon as it is not used frequently. Develop and provide training to staff on procedures. Staff was clear that this would not be the sole responsibility of the health department. Tracking would be followed by hospital and using hotline information provided by the state. The only recommendation would be to understand that the health department does not need to be the sole monitoring system for adverse reactions to medication. There will be other ways to access this information besides taking every call in county. Belmont County Plans indicate that a hotline will be set up to receive adverse events. Need to reach out to health partners to provide us information about adverse events following events, many of their clients may be reluctant or unable to communicate to us. Coshocton County Record keeping of those that receive countermeasures or 27 Page

prophylaxis will be used to track outcomes and potential adverse events. Noble County The form is filled out and forwarded on to the State of Ohio. Jefferson County Establishment of a post treatment supervised recovery area is incorporated into the HCHD ERP and was activated during the exercise. Task # 4.2: Inform patients about follow-up requirements (e.g., vaccine take assessment). Our staff is knowledgeable and able to inform patients quickly and efficiently. Perry County Vaccine intake assessments sheets were dispensed. Morgan County It was discussed to educate the public about additional symptoms or treatments. 28 Page

Unsure Was not discussed. Non-Existent Belmont County POD plan details distribution of information with medication, at exit of POD, and the use of the media and other outlets to remind the public of follow-up information. Coshocton County Patients will receive preprinted literature about the medication given or procedure performed as well as any follow up information needed. Noble County Written information is given to patients and follow up is done with general protocols put out through the media and social media to ensure patients self-monitor after vaccines or antivirals are given. Jefferson County Patient education materials were discussed as being necessary to be issued to clients. Performance Target Capability Activity # 5: Demobilize 29 Page

Associated Critical Tasks Task # 5.1: Debrief POD staff and support personnel. Debriefings were timely, concise and clearly understood by all staff. Perry County Hot wash and debriefing were done. Morgan County ICS Form 221 was referred to and used as a guide for the demobilization. Staff seemed well versed in the debriefing and demobilization process. There were discussions about a "hot wash" and "after action report". As a reminder, I would recommend that the staff realize that once the POD to the public is over, the debriefing and demobilization is just as important as the set up. To get better as a team, staff needs to learn from mistakes and have positive input as to what could be changed to be better. 30 Page

Belmont County Were familiar with staff debriefing but were unsure if it was mandatory and what they would be debriefed about. Work with local CSIM officials and attend a training concerning debriefing. Coshocton County Debrief of staff and personnel are covered in the existing health departments COOP. Noble County Staff meets regularly to critique operations. Jefferson County Staff discussed demobilization accordingly. Task # 5.2: Complete administrative items following the order to demobilize. Knowledgeable staff and exercises have made this task routine for our department. Perry County Everyone knew what to do and when because they practice this at least once per year. Practice even more. Morgan County 31 Page

POD directors are required by local protocol to oversee the complete closure of their POD from supplies to paperwork. Staff seems well versed on physical demobilization. What I am unsure of is the level of understanding of state procedures as it relates to SNS and all the documentation required and where it goes once POD procedures are over. Staff needs further SNS training. Belmont County Were familiar with demobilizing staff and supplies (sending home, make sure they have their stuff, etc.) We re not sure who would be responsible for property damages, overtime and reimbursement of partners. Coshocton County Inventory, essential / non-essential tasks and other duties or actions are covered in existing COOP. Noble County Department as a whole is good at administrative activities day to day and thus also during emergencies. The plan dictates where records are kept. Jefferson County Staff discussed demobilization accordingly. 32 Page

The Jefferson County Health Department performed admirably throughout the exercise, exhibiting its operational readiness to address a difficult matter. Though this exercise did not reveal any significant deficits in the planning or response systems, it was beneficial in bringing staff together to rehearse and re-familiarize employees whose specialties in various disciplines can individually contribute to successful response to a major incident. 33 Page

SECTION 4: CONCLUSION Exercises such as this one allow personnel to validate training and practice strategic and tactical prevention, protection, response and recovery capabilities in a risk-reduced environment. Exercises are the primary tool for assessing preparedness and identifying areas for improvement, while demonstrating community resolve to prepare for major incidents. Exercises aim to help entities within the community gain objective assessments of their capabilities so that gaps, deficiencies, and vulnerabilities are addressed prior to a real incident. Exercises are the most effective (and safer) means to: Assess and validate policies, plans, procedures, training, equipment, assumptions, and interagency agreements; Clarify roles and responsibilities; Improve interagency coordination and communications; Identify gaps in resources; Measure performance; and Identify opportunities for improvement. This exercise succeeded in addressing all of the above as it provided examples of good to excellent participant knowledge, teamwork, communication and use of plans and procedures while pointing out areas in need of improvement and clarification. Listed below is a summary of the level of performance the Target Capabilities and Tasks evaluated during the exercise. This summary outlines the areas in which the local public health agencies are strong as well as identifying areas that the departments should invest future planning, training and exercise funds on. Medical Countermeasure Dispensing / Mass Prophylaxis Activity Target Capability Performance # 1 # 2 Direct Medical Countermeasure Dispensing / Mass Prophylaxis Tactical Operations Activate Medical Countermeasure Dispensing / Mass Prophylaxis # 3 Conduct Medical Countermeasure Dispensing # 4 Adverse Events Monitoring # 5 Demobilize 34 Page

APPENDIX A: IMPROVEMENT PLAN This Improvement Plan has been developed specifically for the Southeast Ohio Public Health Region based on the results of Operation POD Squad - A Point of Dispensing Functional Exercise - Southeast Ohio conducted on June 18, 2013. These recommendations draw on both the After Action Report and the After Action Conference. Capability Observation Recommendation Direct Mass Prophylaxis Tactical Operations Responsible Agency Completion Date Activate Mass Prophylaxis Conduct Mass Dispensing Adverse Events Monitoring Demobilize 35 Page

APPENDIX B: PARTICIPANT FEEDBACK (3 THUMBS UP 3 THUMBS DOWN) Noble County Worked well as a team. Liked the ONX System capabilities. Thumbs Up Plan works well if used and relied on our past experiences. Plans were all in one notebook for easy access. Staff was familiar with plans after individually reviewing them earlier this year. The two PODs had been visited and notebooks were complete. Morgan County Team worked well together and easily took on ICS roles. Easily identified and contacted community partners. Initial HAN alerting and planned communication pathways were in place. Great participation by all staff. Excellent existing plan. Communications with RCC was very efficient. Perry County Just-in-time training manual has already been developed and easily accessed for volunteer training. We have a shared drive to post information to so all staff members have access to it. We were able to contact all of our partners during the exercise. Perry County Just-in-Time training manual has already been developed and easily accessed for volunteer training. We have a shared drive to post information to so all staff members have access to it. We were able to contact all of our partners during the exercise. 36 Page

Participation. Plans were available and utilized. Perry County Just-in-Time training manual has already been developed and easily accessed for volunteer training. We have a shared drive to post information to so all staff members have access to it. We were able to contact all of our partners during the exercise. Perry County We need to update all plans on the shared folder so everyone has access to it. We need to include the HAN directory and updated ICS forms on the shared folder. We need to check to make sure all of our MOU's are updated and if not get them updated. The exercise flowed well. Resources were readily available. Exercise made us communicate and see point of view from other employees. Use of the resources to ultimately complete the objectives. Exercise format. Good communication among team members. Very detailed and informative information and drill. Teamwork. The flow of the drill. Good participation. Our plan worked. Representatives from law enforcement and the hospital took time out of their busy 37 Page

schedules to participate. We finished the exercise in the time allotted. We were able to reference our plans. There was great team work. Great communication. Great plans in place. Perry County We need to update all plans on the shared folder so everyone has access to it. We need to include the HAN directory and updated ICS forms on the shared folder. We need to check to make sure all of our MOU s are updated and if not get them updated. Discussion and cooperation. Knowing people can work well together. Organization of the exercise. Using the Response Plan. The volunteers that are available in the county. Printed materials were helpful. Group discussion. Community partnership presence. The group performing the exercise worked well as a group and communicated openly. It was easy to build consensus as a group. Aspects of the SNS, ERP and ICS structure that need built out or attention were identified. Staff and community attendance. Staffs awareness of Emergency Response Plans even though they may fully not understand their purpose. 38 Page

Exercise discussion. Having multiple positions at the table made for conversation on how to approach the situation. Everyone was able to discuss their ideas openly. There were several community partner representatives at the table along with the health department. Everyone was allowed input, no ideas were shut down, and all suggestions were taken into consideration. Already having some sort of a plan, our response plans, POD plans, SNS, etc. Input from a variety of people was very frustrating at times, but with all the additional eyes and ears on the project, we were less likely to miss steps and were reminded not to make assumptions. More people made the process longer, but more thorough. Access to guidance documents was helpful. Representation from a variety of departments and community partners. Experience of the group. Law enforcement was really not asked much about who, what, where, when or why we would do or not do something during this exercise. It seemed that all members were able to participate and knew what their roles were. We were able to stay on time with the exercise. There are many resources available for us to utilize in order for us to activate a POD. Participation by everyone that was in the exercise. I had a better understanding of what needs to be done if there would be an influenza pandemic. That we have a plan. Perry County 39 Page

Just in-time training manual has already been developed and easily accessed for volunteer training. We have a shared drive to post information to so all staff members have access to it. We were able to contact all of our partners during the exercise. Belmont County Communication between staff. Experience and knowledge of personnel. Completed exercise in a timely manner. The team utilized the existing plans for reference while responding to the injects. Errors, omissions and strengths within the plans were identified by the team. Very good response dialogue, valuable in the aspect that many of the team members are new to their positions. Plans were tabbed and color coded. Plans had been updated recently. Staff worked together well. Staff participation - it was the best we have had. Communications with the RCC. It is a great benefit to have a Regional Coordination Center to communicate with so the entire region is on the same page. Exercise subject matter was very good. We utilized our plan and the questions were pertinent to our health department. Our staff / participants worked together well to review scenario, as well as All Hazards Emergency Response plan and collaboration was good. Staff was familiar with All Hazards plans and participating individuals knew their roles well. Appropriate staff were able to participate in this exercise. Belmont County Communication of staff members. 40 Page

Knowledge base of participants. Completed in a timely manner. Perry County Just-in-Time manual for volunteers has already been developed and easily accessible for volunteer training. We have a shared drive to post information on for all staff to read. All staff have access to it. We were able to contact all of our partners during the exercise. Belmont County Open communication with staff that participated. Utilized plans in place. Exercise had a good flow. Plans already in place. Number of partners involved. The health department uses yearly Flu Clinics to practice their plans and it showed in this exercise. Communications between players. Belmont County Communication among staff present. Experience and knowledge of staff present. Proceeded through exercise in a timely manner. Our plans are in good order. Staff has been here a long time and knows what to do. We do drive thru flu shots at both of the POD sites every year. All departments work really well together. Keeping our plan current and reviewing it frequently really helps in these training exercises. 41 Page

Our staff being experienced in mass vaccination and drive thru clinic has prepared us for this exercise. All staff worked together as one team to complete the exercise. Staff members readily contributed their knowledge and expertise to the areas of the exercise that pertained to them. Staff was able to identify and allocate the resources needed to complete the exercise in a timely manner. Staff with more experience was available to help newer staff assigned to these duties. Excellent participation and collaboration. Well written plan by our planner. Great communication with RCC. The user-friendly, web-based process is an effective training medium. The exercise directives induced good, pertinent conversations. This web-based exercise allowed participants at all levels of ICS to have a total access view of our department's response plan. They weren't just tasked with an assignment to complete for the duration of the exercise. It allowed everyone to view the "big picture" while developing the steps of the smaller picture. Great teamwork, knowledge of plans, ICS roles are used and excellent communication. Coshocton County Had a plan for everything. Players knew their roles. On a regional level, the RCC was set up and staffed with Epidemiologists, nurses and the regional coordinator. This provided resources for the local health departments to go if necessary. The communication and use of the MARCS radio went smoothly. Emails also helped to keep LHD's and regional staff well informed. LHD's were allowed to work through the situation in their own time, without rules. Guidance was available to the LHD's but the RCC allowed LHD's to work through the scenario without being micromanaged, which helped the LHD's identify strengths and 42 Page

weaknesses better. Coshocton County The cooperation between the departments. The availability of event specific plans. Jefferson County Able to exercise at our health department. All in attendance worked well together. Timely exercise. Finding the disaster plan to be complete. Working together with all staff. Jefferson County Good knowledge of our EOP. Cooperation between the groups. Very good exercise. I prefer exercising in this way. Perry County The Just In Time training manual had already been developed and easily accessible. We have a shared drive at our department to post all our documents. We were able to contact our partners during the exercise and obtain what we needed. Morgan County The team was ready to assemble and do the job. Team members knew local resources. The team had a variety of perspectives that went well in developing the plan of action. Coshocton County The Coshocton County and City Health Departments all have encompassing plans and staff works jointly through issues and problems Great communication among other partner agencies. Morgan County The participants knew who to call and the call was made promptly. Everyone knew there role. 43 Page

Decisions were made quickly. Plans were opened! Staff had discussion about plans and worked together to find answers. Staff realized they were not very well versed on plans. Everyone worked well as a team and knew their roles. The planner has a well written and well organized disaster plan. Completed situation in a timely manner. Morgan County Participants worked well together. Resources contacted quickly. Exercise process was set up to enable a smooth completion. Perry County Just-in-Time training manual has already been developed and easily accessed for volunteer training. We have a shared drive to post information to so all staff members have access to it. We were able to contact all of our partners during the exercise. Noble County Group input. Understanding of roles that are needed. Cooperation among agencies responding to requests. Coshocton County Agencies have developed good working relationships that help put our emergency preparedness plans into actions. We have emergency preparedness plans in place to assist us in our response. The exercise was a great learning opportunity for everyone who participated. Coshocton County County and City Health Departments work well together. Going over each other's emergency plans helped to know who was responsible for 44 Page

what. Having the input of everyone helped to show different points of view. Team worked well together, good communication between team members. The ability to refer to a very well developed and organized all hazards response plan, made the exercise run smoothly. Collaboration with the RCC. Coshocton County We had a plan of action for every aspect. Local partners and POD locations were still updated and willing to participate in such an event. Morgan County Worked well as team. Knew who to contact. We were aware of the local contacts. Great team work. Excellent plan. Quick communication with RCC through e-mail. Coshocton County Emergency plans available to use. Good collaboration among agencies. Able to make contact with community partners. Exercise was realistic and appropriate for health departments. Noble County I liked using this ONX System with us displaying it up on the screen. I kept us all on same items, could not read ahead etc. The video clips added nice touch. Our current HD leadership has considerable experience in Pandemic Flu so this was fairly easy. We could end at our own pace. Noble County Information was well presented with our current IT system. 45 Page

Our written plan was very useful. The exercise fostered very good group discussions. Others were able to convey previous personal experiences encountered in previous disasters. Noble County Good participant interaction. Good format. Plan was very easy to follow. Team worked together. Everyone knew their role. Jefferson County The employees of the Jefferson County Health Department worked well together as a team, each offering contributions from their specialized field to contribute to the overall response goal. Planning department was well rehearsed in response program and was able to meet all expectations with regards to MOU s with key stakeholders and response partners. Contact information for partners critical to the Incident Action Plan were readily available in all incidences when challenged by the exercise. Thumbs Down Noble County Add a way to upload documents or files as an attachment instead of giving POC list and equipment or resource listings. Become more familiar with our local plan. The POD notebooks were not with the plans in the binder separate. Staff did not understand the HAN directory in comparison to the resource list. Some confusion about staff placement is positions not necessarily being their normal day to day duties at the health department. Morgan County Staff shortages need corrected and include availability of physicians is identified as an issue. Lack of local media presence. 46 Page

Language barriers identified need addressed. (Chinese, visual / hearing impaired, etc.) Update local agency contacts Review Liability / Workers Compensation issues for MRC volunteers. Depth of ICS coverage (staffing). Perry County We need to update all plans on the shared folder so everyone has access to it. We need to include the HAN directory and updated ICS forms on the shared folder. We need to check to make sure all of our MOU s are updated and if not get them updated. Knowledge of plans. Perry County Just-in-Time training manual has already been developed and easily accessed for volunteer training. We have a shared drive to post information to so all staff member have access to it. We were able to contact all of our partners during the exercise. "Family" should be defined for further use. Staffing levels are at an all-time low. We need to find a way to recruit more people and volunteers. We need to have better involvement from all supervisor levels, not just a couple. Inter-agency co-operation, some team members speak down to and do not listen to the contributions of all the exercise players (the "know it all" syndrome). The actual utilization of the tools that were provided, we had the tools but often taken too long to find and use them. Although it is nice to be aware of the resources needed, it took way too long to catalogue what we would need in certain parts of the exercise. Even in listing these resources many were left out because of the time allotted. Engage more partners. 47 Page