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GLOBAL INFLUENZA PROGRAMMESELECTINGAN EXERCISEPLANNINGTHE EXERCISEDEVELOPINGTHE SCENARIODESCRIBINGTHE PANDEMICEVALUATINGPLANNINGSTAGINGTHE EXERCISEAFTERTHE EXERCISEA practical guide fordeveloping and conductingsimulation exercises to testand validate pandemicinfluenza preparedness plans1

ISBN 978-92-4-151450-7 World Health Organization 2018Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercialShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; go).Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercialpurposes, provided the work is appropriately cited, as indicated below. In any use of this work, thereshould be no suggestion that WHO endorses any specific organization, products or services. The useof the WHO logo is not permitted. If you adapt the work, then you must license your work under thesame or equivalent Creative Commons licence. If you create a translation of this work, you shouldadd the following disclaimer along with the suggested citation: “This translation was not created bythe World Health Organization (WHO). WHO is not responsible for the content or accuracy of thistranslation. The original English edition shall be the binding and authentic edition”.Any mediation relating to disputes arising under the licence shall be conducted in accordance withthe mediation rules of the World Intellectual Property Organization.Suggested citation. A practical guide for developing and conducting simulation exercises totest and validate pandemic influenza preparedness plans. Geneva: World Health Organization;2018. Licence: CC BY-NC-SA 3.0 IGO.Cataloguing-in-Publication (CIP) data. CIP data are available at http://apps.who.int/iris.Sales, rights and licensing. To purchase WHO publications, see http://apps.who.int/bookorders.To submit requests for commercial use and queries on rights and licensing, see http://www.who.int/about/licensing.Third-party materials. If you wish to reuse material from this work that is attributed to a third party,such as tables, figures or images, it is your responsibility to determine whether permission is neededfor that reuse and to obtain permission from the copyright holder. The risk of claims resulting frominfringement of any third-party-owned component in the work rests solely with the user.General disclaimers. The designations employed and the presentation of the material in thispublication do not imply the expression of any opinion whatsoever on the part of WHO concerningthe legal status of any country, territory, city or area or of its authorities, or concerning the delimitationof its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines forwhich there may not yet be full agreement.The mention of specific companies or of certain manufacturers’ products does not imply that they areendorsed or recommended by WHO in preference to others of a similar nature that are not mentioned.Errors and omissions excepted, the names of proprietary products are distinguished by initial capitalletters.All reasonable precautions have been taken by WHO to verify the information contained in thispublication. However, the published material is being distributed without warranty of any kind, eitherexpressed or implied. The responsibility for the interpretation and use of the material lies with thereader. In no event shall WHO be liable for damages arising from its use.ii

AcknowledgementsWHO wishes to acknowledge the contributions of all who reviewedand commented the document during the public comment period.The individuals who identified themselves are listed below:S. Bonnaz, J. Gregg, N. Isla, B. Jester, N. Khuri-Bulos, I. Martin-Loeches,P.M. Muthoka, B. Paterson, H. Rebelo-de-Andrade, P.J. VincentThe following WHO staff and consultants were involved in thedevelopment and review of this document and their contributionsare gratefully acknowledged:A. Bell, I. Bergeri, A. Black, S. Briand, C.S. Brown, F. Copper, P. Cox,S. Chungong, E.L. Dueger, P. Gould , B.L. Herring, M. Hegermann-lindencrone,S. Hirve, M. Kato, Q.Y. Khut, J. Lamichhane, M. Malik, A. Moen, B. Olowokure,R. Palekar, S. Rajatonirina, B. Shrestha, G. Samaan, M. Samaan, K. Vandemaele,W. Zhang, W. Zhou.iii

1Selecting an exercise describes considerations to take into accountwhen choosing an appropriate exercise for the plan being tested,and setting exercise aims and objectives.SELECTING2PLANNINGPlanning the exercise outlineskey steps to take when planningand managing the exercise.43DEVELOPINGDeveloping the scenario providesguidance on how to research and planthe exercise scenario and injects.5DESCRIBINGDescribing the pandemic outlinesdifferent pandemic influenza-specific variablesthat can be incorporated into the exercise scenario.Planning the evaluation describes the stepsneeded to build an evaluation team and develop arobust evaluation plan for the exercise.EVALUATINGAFTERTHEEXERCISE7After the exercise suggestsa process to take use theoutcomes of the exerciseto initiate the review andimprovement and pandemicinfluenza preparedness plans.6STAGINGivStaging the exercise outlines key actionsneeded to set up and conduct the exercise.Developing and conductingsimulation exercises to testand validate pandemic influenzapreparedness plans

Contents1.Introduction1.11.22.Selecting an exercise2.12.22.32.43.5.Exercise management teamExercise planTarget audienceParticipantsFacilitationExercise guide and briefingsAdditional elements3.7.1 Communications and media3.7.2 Safety and security3.7.3 Stopping the exercise in an emergencyDeveloping the iew 13Context research 13Planning the scenario 144.3.1 Injects 144.3.2 Delivering injects 154.3.3 Scenario planning documents 154.3.4 How many injects should there be?15Describing the pandemic: scenario variables164.4.1 Pandemic phases164.4.2 Where does the pandemic start?174.4.3 Characteristics of the virus174.4.4 Dynamics and impact18Tips214.5.1 Stay organised214.5.2 Do not fight the scenario214.5.4 How much detail is needed?21Planning the evaluation5.15.25.35.45.53333Scoping the exercise4Setting the aims and objectives4Types of exercise5Choosing the type of exercise62.4.1 What is being tested? 62.4.2 What resources are available?7Planning the exercise3.13.23.33.43.53.63.74.OverviewHow to use this guide1.2.1 Purpose1.2.2 Audience3OverviewIdentify the evaluatorsExternal or internal evaluatorsEvaluation plan5.4.1 Evaluation questions5.4.2 Assessment criteria5.4.3 Data collection and toolsEvaluator orientationworld health organization2323232424242526261

6.Staging the exercise6.16.27.Setting up the exercise6.1.1 Exercise venue6.1.2 Control room6.1.3 Equipment check6.1.4 Exercise management team briefingConducting the exercise6.2.1 Participant and observer briefing6.2.2 Welcome and opening6.2.3 Starting the exercise6.2.4 Running the exercise6.2.5 Observing the exercise6.2.6 Ending the exercise6.2.7 Hot wash exercise debriefing6.2.8 Main exercise debriefing6.2.9 ClosingAfter the 33334OverviewExercise management debriefings7.2.1 Exercise management team debriefing7.2.2 Leadership debriefingReporting7.3.1 Exercise report and recommendations7.3.2 Internal mission reportImplementing improvements7.4.1 Circulate draft exercise report to stakeholders7.4.2 Hold a post-exercise workshop to develop and endorse an action plan7.4.3 Monitor implementation of improvement actions7.4.4 Hold an action plan follow-up 38Annex 1.Annex 2.Annex 3.Annex 4.Annex 5.Annex 6.384143454951ResourcesGlossarySample exercise planSample evaluation plan and checklistSample participant feedback formSample exercise scenarioa practical guide for developing and conductingsimulation exercises to test and validate pandemic influenza preparedness plans

1.1.1IntroductionOverviewInfluenza pandemics are recognized as unpredictable but recurring events that can haveserious consequences on human health and economic well-being worldwide. Advanceplanning and preparedness is critical for countries to mitigate the risk and impact of apandemic, ensuring that they have sustainable and resilient capacities for an efficientpandemic response.Considerable efforts and resources have been invested by countries around the world indeveloping national pandemic influenza preparedness plans and the capacities neededto respond to an influenza pandemic. However, to be effective, plans need to be tested,validated and updated periodically through simulation exercises.In 2017 and early 2018, WHO published several key documents to support globalpandemic preparedness efforts. The pandemic influenza risk management (PIRM)document (1) and its supporting checklist (2) update the previous WHO pandemicpreparedness guidance and checklist with lessons learned from the 2009 influenzapandemic, introduce the strategies and approaches in pandemic influenza risk and impactmanagement, and emphasize the importance of national risk and severity assessments inguiding the national response actions. The WHO simulation exercise manual (3) providesguidance on the concepts and principles for conducting and managing simulationexercises. This current guide is derived from those guiding documents. It focuses ondeveloping and conducting simulation exercises to test and validate national pandemicpreparedness plans – an essential step in the pandemic influenza preparedness planningprocess (4).1.2How to use this guide1.2.1 PurposeThe purpose of this guide is to support countries in their testing and updating of theirnational pandemic influenza preparedness plans. It is intended to provide guidance onhow to select, plan, conduct and evaluate simulation exercises specific to pandemicinfluenza, and how to set up a process for using the outcomes of these exercises to reviewand improve pandemic plans.This guide should be read in conjunction with the PIRM document (1), which providesspecific technical guidance on pandemic planning, and the WHO simulation exercisemanual (3), which provides such guidance on simulation exercises.Additional resources for pandemic influenza planning and simulation exercises can be found in Annex 1,and a glossary in Annex 2.1.2.2 AudienceThis guide is intended to be used by national agencies responsible for pandemic influenzapreparedness planning. It can also be used by other organizations involved in buildingpandemic preparedness capacity, or as a reference document for individuals or agenciesinvolved in public health emergency planning.world health organization3

2.2.1Selectingan exerciseScoping the exerciseScoping the exercise involves meeting with the host organization and key stakeholders to agreeon the exercise aim, objectives, scope and type. Other important issues that should be discussedinclude the target audience for and participants in the exercise, expected outcomes, timeline,budget and exercise management.The final agreements made during this process should be circulated to stakeholders for futurereference (e.g. in a concept note).2.2Setting the aims and objectivesSetting the aim and objectives for an exercise is an obvious first step, but is one that often doesnot receive enough consideration. It is essential that the aim and objectives are clear and welldefined – they are the foundation of the exercise and they describe the specific outcomes to beachieved. If the aim and objectives are ambiguous or too general, it will be difficult to understandthe purpose of the exercise and to evaluate its result.The aim defines the scope and overall planning framework of the exercise. A successful andproductive exercise is directed at a specific aim; for example, to test a component or componentsof an existing pandemic influenza preparedness plan and identify areas for improvement.The objectives specify how the aim will be achieved, and will determine how the exercise isdesigned. They influence the type of exercise chosen, who should be invited to participate, howthe scenario is developed and how the exercise will be facilitated and evaluated. The objectivesshould be clear, measurable and attainable. This will allow you to develop assessment criteria toevaluate the outcomes of the exercise and identify improvements or revisions to the plan beingtested.Setting a clear aim and objectives will also help in communicating the purpose of the exerciseto participants and stakeholders. If participants have a clear understanding of the aim andobjectives, they will be able to perform better and will also be able to provide specific feedbackon the outcomes of the exercise. Similarly, if stakeholders and senior management have such anunderstanding, they will be able to support and advocate for the exercise. Box 2.1 shows the aimand objectives of a sample exercise.Box 2.1. Sample exercise aim and objectivesThe aim of a sample exercise could be: to test [selected components] of the pandemic influenza preparedness plan inorder to identify areas for revision or improvement.The objectives of a sample exercise could include testing: the functionality and speed of decision-making procedures in the plan in orderto identify areas for revision or improvement; formal or planned coordination, communication and information-sharing mechanismsbetween relevant departments and agencies involved in the pandemic response; and existing capabilities (resource, logistics and support) for an operational response to aninfluenza pandemic according to the plan, and identifying capacity-strengthening needs.4a practical guide for developing and conductingsimulation exercises to test and validate pandemic influenza preparedness plans

When deciding on the objectives of the exercise, it is important to be realistic about what can beachieved with the resources available. Increasing the number of objectives will also increase thescope, complexity and cost of the exercise. A small number of well-defined objectives is oftenbetter than a large number of objectives.Generally, it is not possible to test all of the components of a pandemic influenza preparednessplan in a single exercise, owing to time or resource constraints. Rather than running a singlelarge-scale exercise to test the entire plan, it may be better to hold a series of smaller exercisestargeted at testing and validating specific components of the plan. Such exercises will be moremanageable, and will also help to develop a culture of exercise, practice and revision withinparticipating organizations.2.3Types of exerciseThere are four basic types of simulation exercise, and these can be categorized as eitherdiscussion-based or operations-based exercises: Discussion-based exercises develop, refine or familiarize participants with current plans,policies, agreements and procedures. Tabletop exercises are the most common form ofdiscussion-based exercises. Operations-based exercises are used to validate the functionality of plans, policies,agreements, procedures and systems; clarify roles and responsibilities; and identify resourcegaps in operational environments. They include drills, functional exercises, and full-scale or fieldexercises.Where necessary, hybrid exercises that integrate elements of different exercise types can alsobe developed, For example, a full-scale or field exercise can be developed that also incorporateselements from a functional exercise, or includes a series of drills. Details of the four types ofsimulation exercise are given in Table 2.1.Table 2.1. Types of simulation exerciseEXERCISE TYPEDESCRIPTIONTabletop Develop or reviewA tabletop exercise is a facilitatedpreparedness plans.discussion of an emergency situation, Familiarize participantsgenerally in an informal, low-stresswith their roles andenvironment. It is designed to elicitresponsibilities.constructive discussion between Identify and solve problemsparticipants in order to identify andthrough facilitated andresolve problems and refine existing plans.open rld health organizationA drill is an exercise that is normallyfocused on testing or practising a specificfunction or process in a preparednessplan. Drills should be as realistic aspossible, making use of actual facilitiesand equipment necessary for the functionbeing tested.USES Train staff in newprocedures, or in the useof tools or equipment. Exercise or maintain currentskills. Test a specific operation(e.g. an emergencycommunication tree). Develop new policiesor procedures.5

Table 2.1. Types of simulation exercise [continued]EXERCISE TYPEFunctionalOperations-basedFull-scale or fieldOperations-basedDESCRIPTIONUSESA functional exercise is a fully interactiveexercise that tests the capability of anorganization to respond to a simulatedevent in a time-pressured environment.Functional exercises focus on the coordination, integration and interaction ofan organization’s policies, procedures,roles and responsibilities before, during,or after the simulated event. Test the operationalsystems, procedures andplans that are currently inplace. Identify strengths, gapsand opportunities forimprovement. Enhance the capacity ofthe operational system torespond to an emergency.A full-scale exercise is designed to testthe operational capability of emergencymanagement systems in the mostrealistic manner possible. The exercisesimulates actual response conditionsin a highly stressful environment,and includes the mobilization andmovement of emergency personnel,equipment and resources. Full-scaleexercises typically involve multipleagencies and participants physicallydeployed in a field location. Ideally,the full-scale exercise should testand evaluate most functions of theemergency management plan oroperational plan. Test the operationalemergency responsecapacity of teams andorganizations. Test the functions of theemergency managementplan or operational plan. Practise coordination,communication andcollaboration betweenmultiple entities andstakeholders. Identify strengths, gapsand opportunities forimprovement. Enhance the capacity of theemergency managementsystem to respond to anemergency.A field exercise is a form of full-scaleexercise that focuses on a specificcapacity or function. It is less complexthan a full-scale exercise, but isdeveloped and implemented in a similarfashion.Contents adapted from the WHO simulation exercise manual (3).2.4Choosing the type of exerciseThe type of exercise that is appropriate in a particular situation will depend on what is being testedand what resources are available.12.4.1What is being tested?Selecting the right type of exercise will help to achieve the objectives of the simulation. Forexample, if the objectives include training or orienting new staff to pandemic preparedness plans,a tabletop exercise or drill may be appropriate. However, if the objectives include practising andrefining the established procedures of an emergency response plan, a functional or full-scaleexercise may be more useful.16Also see “Appendix A: Job Aid 3, Self-assessment – resources and costs”in the WHO document on development of emergency exercises (5).a practical guide for developing and conductingsimulation exercises to test and validate pandemic influenza preparedness plans

The type of exercise chosen will also be influenced by the components of the pandemicpreparedness plan to be tested: strategic components are often suited to discussion-based exercises, such as atabletop exercise; operational components can be suited to discussion-based or operation-based exercises,such as tabletop, functional or full-scale exercises; and guidelines or standard operating procedures (SOPs) are often suited to operation-basedexercises that focus on a specific function, such as drills or field exercises.Table 2.2. Example exercises to test pandemic influenza preparedness plansPLANSAMPLE AIMCOMPONENTStrategicOperationalGuideline orSOPSAMPLE OBJECTIVESSUGGESTEDEXERCISE TYPETo test decisionmaking andcoordinationmechanismsbetween responsepartners in thenational strategicpandemic influenzaplan.To test the decision-makingmechanisms within thepandemic influenza incidentmanagement system.To test operationalplans for health-carefacilities during apandemic influenzaresponse.To test the mechanisms forestablishing planned pandemicinfluenza health services andsuspending nonessential healthservices.TabletopTo test the functionality offacility-level plans for triage andpatient flow.FunctionalTo test systems for coordinationin near real-scale operations.Full-scaleTo test the feasibility andadequacy of existingguidelines or SOPs for outbreakinvestigation and eventverification.DrillTo test the efficiency of rapidresponse team deployment(e.g. HR, administration andlogistics).FieldTo test guidelineson rapid responseto suspected casesof novel influenza inhumans.TabletopTo test the effectiveness offormal or planned coordinationand communicationmechanisms between relevantdepartments and agencies.HR, human resources; SOP, standard operating procedure.2.4.2What resources are available?The amount of resources required will vary widely, depending on the type of exercise, and its scope,complexity and scale. Well-run simulation exercises can be extremely resource intensive; hence, itis important to be realistic about the amount of resources (particularly time and staff ) that will beneeded. A further consideration when choosing an appropriate exercise type is the capacity andexperience of the organization managing the exercise. Organizations should build experience withbasic exercises before progressing to more complex ones. Table 2.3 summarizes the cost, time andhuman resources required for the different exercise types.world health organization7

Table 2.3. Exercise types and estimated resource requirementsEXERCISETYPETabletopCOST Exercise conduct: 3–8 hoursPlanning and follow-up: 1 monthDrill – Exercise conduct: 0.5–2 hoursPlanning and follow-up 1 monthFunctional Exercise conduct: 4–8 hours; or multiple daysPlanning and follow-up: 2 monthsFull-scale orfield – HUMANRESOURCESTIMEExercise conduct: 2–4 hours; or 1–5 days.Planning and follow-up: Full-scale: 6 months Field: 8-12 weeks Exercise directorAt least 1 facilitatorAt least 1 evaluatorTechnical expertsAdministration andlogistics staff Exercise directorFacilitatorsEvaluatorsTechnical expertsLocal advisersAdministration,logistics staff Exercise directorFacilitatorsEvaluatorsTechnical expertsLocal advisersAdministration,logistics and ICT staff Exercise directorControllerFacilitatorsEvaluatorsRole players or actorsTechnical expertsLocal advisersAdministration,logistics and ICT staffICT, information and communications technology.Adapted from the WHO simulation exercise manual (3).KEY POINTS – Section 2 Agree on a document that sets expectations for the exercise (e.g. a concept note)and circulate this to stakeholders. Set a small number of clear, well-defined objectives – less is often better. Clearly communicate the aims and objectives of the exercise to everyone involved. When choosing an exercise, consider the: aim and objectives of the exercise; type of plan being exercised; and level of human and financial resources you can commit. Exercises can be extremely resource-intensive – do not underestimate the time,staff and funds you will need. Build organizational experience with basic exercises (e.g. a series of small exercisesto test specific components of the plan) before moving to more complex ones.8a practical guide for developing and conductingsimulation exercises to test and validate pandemic influenza preparedness plans

3.3.1Planningthe exerciseExercise management teamThe exercise management team is the group of people responsible for planning, conducting,evaluating and following-up the exercise. The exact composition of the team will depend on thetype, scope and complexity of the exercise and will typically include some, or all of the followingroles: Exercise director: The exercise director oversees the planning, conduct and evaluation ofthe exercise, and is responsible for appointing and managing other members of the exercisemanagement team. Exercise controller: In operation-based exercises, the exercise controller (also known asthe lead facilitator) supervises the conduct of the exercise. The controller is responsible forintroducing injects to the exercise, through messages, facilitators or role players; these are smallpieces of information that are used to manage the speed and direction of exercise play. Facilitators: Facilitators are the first point of contact for questions or requests from participantsduring an exercise. They are responsible for helping participants to understand the objectivesand come to a consensus. During operation-based exercises, facilitators deliver injects and helpto monitor the progress of the exercise by providing feedback to the controller. During tabletopexercises, facilitators present the scenario, keep discussions on track and ensure that topics arecovered as thoroughly as possible in the available time. Role players: In large operational exercises, role players are used to act out or simulate specificpre-scripted roles for participants to respond to. Role players keep to their roles and the scriptedscenario, but are also prepared to improvise if participants respond unexpectedly during theexercise. Evaluators: Evaluators observe and gather data from the exercise to assess whether the aim andobjectives of the exercise were met. They typically evaluate overall performance; operationaleffectiveness, quality, capabilities, strengths and weaknesses; and areas for improvement. Alltypes of exercise require evaluation, but large or complex exercises require a an evaluation teamled by a lead evaluator.3.2Exercise planOnce the exercise management team has been formed, the exercise director should establisha plan for developing and conducting the exercise, in line with the details previously agreed towith stakeholders (e.g. budget, time frame, people, facilities and equipment – see Section 2.1).This exercise plan should define and delegate tasks to appropriate members of the exercisemanagement team. Typical tasks include: administration and logistics (e.g. invitations, participants, materials, venues, facilities,technology and connectivity); site visits to proposed exercises venues; development of scenarios, injects and exercise material; evaluation planning; briefing and training (e.g. of evaluators, facilitators, role players and participants); preparation of debriefing and exercise report; communications and media (for full-scale or field exercises); and safety and security.world health organization9

Good communication within the exercise management team is crucial for developing andmanaging the exercise. Regular team meetings should be held to keep the project on track,and methods should be established for collaborating on exercise materials (e.g. use of a sharedelectronic drive).3.3Target audienceIn addition to participants and stakeholders, the target audience for the exercise includesorganizations and groups with a strategic or operational interest in pandemic preparedness.Examples of such organizations and groups are local government, medical associations, businessor commercial groups, sector representatives or community organizations.Identifying target audiences can create opportunities for multisector engagement in pandemicpreparedness, and wider visibility of the exercise outcomes. For example, you may wish to asklocal medical associations for volunteer role players to join the exercise, or to share the exercisereport with local governments to help strengthen local pandemic preparedness capacities. Adissemination plan for key documents or information materials (e.g. the exercise report) should bedeveloped with this in mind.3.4ParticipantsExercise participants should be identified based on their professional function or role inthe pandemic preparedness plan being tested. They will generally be staff members of theorganizations involved in pandemic preparedness and response. Participation should beprioritized for staff who need experience in practising their response duties, including staff whohave been nominated to back up key roles during a pandemic. Participation of personnel from civilor cultural organizations can also be considered if the scope of the exercise and resources allow.Participants should be invited well in advance of the exercise, to secure their attendance. It can betempting to involve a large number of participants; however, for the success of the exercise it isbest to limit numbers to a manageable level. Large groups will make performance, managementand evaluation more difficult, and thus will decrease the quality of the exercise. Participantswithout a direct role in the pandemic plan or plans being tested are also less likely to be fullyengaged, and can distract others from focusing on the exercise objectives. Box 3.1 provides tipsfor identifying suitable participants.TIPBox 3.1. Tips for identifying participantsInvolving the right participants is critical for the success of the exercise.To help identify participants, it is helpful to: map out the response system and the agencies, functions and people who wouldbe involved in a pandemic response at the level being targeted; and review pandemic response plans, procedures and the internal structures of theorganizations involved.Participation should be limited to people who are directly involved in the responseplans being tested. Too many participants and observers will reduce the quality ofthe exercise and can prevent the objectives from being met.10a practical guide for developing and conductingsimula

2. Selecting an exercise 4 2.1 Scoping the exercise 4 2.2 Setting the aims and objectives 4 2.3 Types of exercise 5 2.4 Choosing the type of exercise 6 2.4.1 What is being tested? 6 2.4.2 What resources are available? 7 3. Planning the exercise 9 3.1 Exercise management team 9 3.2 Exercise plan 9 3.3 Target audience 10