Countermeasures and Emergency Management Considerations

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Countermeasures andEmergency Management
Considerations

• Matthew Minson, MD
• OPSP/ASPR/OS/USDHHS

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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

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CRI Intelligence

• In general the threat consideration is
  substantial
• Aerial dispersion of anthrax over a large
  geographic area can be accomplished with
  commercially-available equipment

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Anthrax Exposure Proportion of
Population Saved
DELAY in Initiation
DURATION of Campaign
7 Days
2 Days
3 Days
4 Days
5 Days
6 Days
Immed.
1 Day
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
1 Day
100
100
99
97
94
89
82
72
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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

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CRI MSA Tables 2006-2007
Table I Combined 36 cities from 2004 - 2006 CRI Table I Combined 36 cities from 2004 - 2006 CRI Table II 36 planning cities for 2006-2007 CRI Table II 36 planning cities for 2006-2007 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 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
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Countermeasure Cascade Generic
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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

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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
Model assumptions
Staff per shift
Staff per POD
Campaign staff
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Countermeasures PODS
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Medical PODs vs.
Non-Medical PODs
Medical PODs Non-Medical PODs
Target Population 1,000,000 1,000,000
PEP duration 2 days 2 days
Hours of operation 24 hr/day 24 hr/day
Number of shifts 2 shifts 2 shifts
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
Model assumptions
Staff per shift
Staff per POD
Campaign staff
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CRI Challenges/Issues

• Staffing (Volunteer)
• State/Local Leadership
• Resistance to Planning (Difficult)
• Security Resources
• Assessment Process
• Population Dynamics (Cooperation)
• Untried Scenario (Battle Conditions)

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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
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Countermeasures

• USPS STRIKE

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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

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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.

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Countermeasures

• HOME STOCKPILING
• MEDKIT

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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

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CRI MEDKIT
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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

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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

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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

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Countermeasure Delivery

• RECENT DEVELOPMENTS

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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.

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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

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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

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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)

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PH SUMMIT Countermeasures Strategy

• Continued issues
• Worker protection
• Medkit
• POD EUA
• Communications Strategies
• Increased interest and Federal amplification of
  USPS option (BARDA Modeling Conclusion)

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Countermeasures

• The Future

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Countermeasures

• QUESTIONS?
• Matt.Minson_at_hhs.gov