Countermeasures and Emergency Management Considerations Matthew Minson, MD OPSP/ASPR/OS/USDHHS
Countermeasure Distribution, Dispensing, and Delivery Current strategies for countermeasure delivery are generally classified by the following: - Post Exposure Prophylaxis PEP (Given to the public after exposure or presumed exposure during a window of incubation) - Therapeutic or Corrective (Given once disease has begun, requiring professional administration) This presentation focuses on the former or mass prophylaxis campaigns This is best described in the CRI context 1
CRI Intelligence In general the threat consideration is substantial Aerial dispersion of anthrax over a large geographic area can be accomplished with commercially-available available equipment 2
Anthrax Exposure: Proportion of Population Saved DURATION of Campaign Immed. DELAY in Initiation 1 Day 2 Days 3 Days 4 Days 5 Days 6 Days 7 Days 10 Days 84% 78% 71% 62% 54% 45% 36% 28% 7 Days 95% 91% 85% 78% 69% 59% 49% 39% 6 Days 97% 94% 89% 83% 75% 65% 54% 43% 5 Days 98% 96% 92% 87% 80% 71% 60% 49% 4 Days 99% 98% 95% 91% 85% 76% 66% 54% 3 Days 100% 99% 97% 94% 89% 81% 72% 60% 2 Days 100% 99% 98% 96 92% 86% 77% 66% 1Day 100% 100% 99% 97% 94% 89% 82% 72% 3
Cities Readiness Initiative CRI GOAL:» distribute antibiotics to the at-risk population up to the entire community» within 48 hours of the decision to do so, (from time of exposure)» Doxycycline, Ciprofloxacin CRI Preparedness Indicators:» robust local capability to dispense antibiotics rapidly over a large geographic area 4
CRI MSA Tables 2006-2007 Table I Combined 36 cities from 2004-2006 CRI Atlanta, GA Baltimore, MD Boston, MA Chicago, IL Cincinnati, OH Cleveland, OH Columbus, OH Dallas, TX Denver, CO Detroit, MI District of Columbia Houston, TX Indianapolis, IN Kansas City, MO Las Vegas, NV Los Angeles, CA Miami, FL Milwaukee, WI Minneapolis, MN New York City, NY Orlando, FL Philadelphia, PA Phoenix, AZ Pittsburgh, PA Portland, OR Providence, RI Riverside, CA Sacramento, CA San Antonio, TX San Diego, CA San Francisco, CA San Jose, CA Seattle, WA St. Louis, MO Tampa, FL Virginia Beach, VA Table II 36 planning cities for 2006-2007 CRI Albany, NY Albuquerque, NM Anchorage, AK Baton Rouge, LA Billings, MT Birmingham, AL Boise, ID Buffalo, NY Burlington, VT Charleston, WV Charlotte, NC Cheyenne, WY Columbia, SC Des Moines, IA Dover, DE Fargo, ND Fresno, CA Hartford, CT Honolulu, HI Jackson, MS Little Rock, AR Louisville, KY Manchester, NH Memphis, TN Nashville, TN New Haven, CT New Orleans, LA Oklahoma City, OK Omaha, NE Peoria, IL Portland, ME Richmond, VA Salt Lake City, UT Sioux Falls, SD Trenton, NJ Wichita, KS 5
Countermeasure Cascade: Generic FED SNS PUSH PACKAGE, MI F F STATE Receiving Staging Storing L. Dist. Center L L pod pod L pod S pod S S pod S pod Locals 6
Cities Readiness Initiative: Goal An initiative to expedite the timeframe to dispense prophylaxis Increase Point of Dispensing (POD) throughput Modified Medical Screening (Non-Medical Model) U.S. Postal Service Delivery Alternate Dispensing Modalities Drive thru clinics Establish PODS with large employers, universities, etc. Using existing delivery services- Meals on Wheels, Home Healthcare, etc. Community strike teams 7
Model assumptions Staff per shift Staff per POD Campaign staff Medical PODs Medical PODs Non-Medical PODs Target Population 1,000,000 1,000,000 1,000,000 PEP duration 2 days 9 days 2 days Hours of operation 24 hr/day 24 hr/day 24 hr/day Number of shifts 2 shifts 2 shifts 2 shifts Patient throughput 500 pts/hr/pod 500 pts/hr/pod 2,000 pts/hr/pod Number of PODs 42 10 11 Core: Public health 19 19 2 Core: Non-public health 33 33 48 Support staff 13 13 10 Total 65 65 60 Core: Public health 44 44 5 Core: Non-public health 76 76 110 Support staff 30 30 23 Total 150 150 138 Core: Public health 1,821 434 48 Core: Non-public health 3,162 753 1,150 Support staff 1,246 297 240 Total 6,229 1,484 1,438 8
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Countermeasures: PODS 10
Medical PODs vs. Non-Medical PODs Model assumptions Staff per shift Staff per POD Campaign staff Medical PODs Target Population 1,000,000 PEP duration Hours of operation Number of shifts 2 days 24 hr/day 2 shifts Non-Medical PODs Patient throughput 500 pts/hr/pod 2,000 pts/hr/pod Number of PODs 42 11 Core: Public health 19 2 Core: Non-public health 33 48 Support staff 13 10 Total 65 60 Core: Public health 44 5 Core: Non-public health 76 110 Support staff 30 23 Total 150 138 Core: Public health 1,821 48 Core: Non-public health 3,162 1,150 Support staff 1,246 240 Total 6,229 1,438 11
CRI Challenges/Issues Staffing (Volunteer) State/Local Leadership Resistance to Planning (Difficult) Security Resources Assessment Process Population Dynamics (Cooperation) Untried Scenario (Battle Conditions) 12
CRI: Dispensing/Delivery PODS POD Standards Project- ASPR, RAND and the DSNS are working together to establish core standard for POD planning and operations MedKit: 8 month study indicated. 97% efficacy First Responders, Clinic, Corporate FDA working in parallel to address commercialization of MedKits CRI/Postal: Postal Option is only one component of a mass prophylaxis plan, meant to buy time for a more thorough Public Health response Greater questions facing the Emergency Management community is how SNS assets will be distributed in a POD structure. Federal, Corporate, Open and Closed PODs 2008, Institute of Medicine Forum for Public Health and Medical Disasters 13
Countermeasures USPS STRIKE 14
Countermeasure Distribution and Dispensing: USPS Delivery 3 Exercises Operational Development: MSP/MN (pilot) Collaborative Dependent on Home stockpiling requirement by the USPS volunteers Threat Designation (DHS), PHED (HHS), EUA (FDA): Oct, 2008 Future Cities have expressed interest 15
USPS and Public Health Emergency Response During the recent combined ice storm debilitation of some communication resources and the need to inform the public of the potential for contaminated peanut products, the USPS successfully delivered print material to residences thus protecting the population of three Midwestern states. 16
Countermeasures HOME STOCKPILING MEDKIT 17
Countermeasure Distribution, Dispensing, and Delivery: Personal Stockpiling MedKit: 8 month study. 97% efficacy First Responders, Clinic, Corporate FDA/BARDA working in parallel to address commercialization of MedKits NBSB rendered opinion: Formalized kit preferable to Discretionary Prescriptions 18
CRI MEDKIT 19
CRI First Responder Issues Based on discussions with the USPS Carrier Union Leadership and Service Management certain requirements for participation were determined PPE (per OSHA/NIOSH) Physical Security (LE) In advance provisioning of Antibiotics for Carrier Volunteers and their families 20
Countermeasure Distribution, Dispensing, and Delivery: Personal Stockpiling Medkit (Home Antibiotic Kits) USPS (HHS Lead) EUA HHS Responder (HHS Lead) EUA DHS Responder (DHS Lead/HHS Support) EUA Traditional First Responder (as above) EUA Greater Population (HHS Lead) Commercial Strategy :NDA 21
CRI RESPONDERS Subsequent Discussions with MSP in have indicated that for POD function and USPS strike team preparations that similar considerations should be provided for their local responders Homeland Security Council undertaking specific countermeasure outreach to FR HSC/DOL/DHS/HHS consideration of unique environmental challenges in CRI 22
Countermeasure Delivery RECENT DEVELOPMENTS 23
PH SUMMIT Countermeasures Strategy In the Fall of 2007 a Forum to address issues related to a successful countermeasure campaign was conducted It determined that dispensing, and delivery held the greatest impediments to success and workshops were scheduled for Spring and Summer of 2008 to address same. 24
PH SUMMIT Countermeasures Strategy Consensus conclusions rendered included: Reducing impediments to Public- Private Collaboration Liability-PREP ACT Forward positioning of assets- cache, personal stockpiling USPS amplification Enhancing communication strategies 25
PH SUMMIT Countermeasures Strategy Since the workshop, a multidisciplinary group has continued to meet and work on these issues State and Local HHS-CDC, FDA, ASPR, OGC, DSNS Industry Academia Non-Governmental organizations 26
PH SUMMIT Countermeasures Strategy Actions: DHS Determination, HHS PH Emergency Declaration, FDA Provision of EUA in October, 2008 MN/MSP/HHS/USPS Operationalizing USPS PREP ACT Declaration Discussion of issues with NBSB, on going Expanded capability at DSNS (first 12 hours) 27
Continued issues Worker protection Medkit POD EUA Communications Strategies PH SUMMIT Countermeasures Strategy Increased interest and Federal amplification of USPS option (BARDA Modeling Conclusion) 28
Countermeasures The Future 29
Countermeasures QUESTIONS? Matt.Minson@hhs.gov 30