1. Ashley Ward Peluso, PharmD, MSCR Pharmacist, Cities Readiness Initiative Region Division of Public Health, Public Health Preparedness & Response NC Department of Health & Human Services The Strategic National Stockpile: Emergency Management’s Role

2. Disclaimer 2 The following presentation on the Strategic National Stockpile and involved partners is for educational purposes only. Local Emergency Management will perform a variety of roles dependent on the scenario of the public health event and also the emergency plans and agreements in place with county partners. If you have specific questions about EM’s role in your county’s Medical Countermeasures Plan, please contact the Preparedness Coordinator at your local health department.

3. Topics Overview of NC Public Health Preparedness & Response CDC’s Strategic National Stockpile Program (SNS) Purpose Components Requesting Assets Deployments Program Oversight Requesting, Receiving, Distributing, and Dispensing the SNS State Emergency Management’s Role Local Emergency Management’s Role Local Health Department’s and PHP&R’s Role NC’s H1N1 Response in 2009 3

4. 4 Overview of North Carolina Public Health Preparedness & Response

5. NC Public Health Preparedness & Response Epidemiology Section of the Division of Public Health Responsibilities: assists with identifying, preventing, protecting against, responding to, and recovering from public health emergencies when local capabilities will likely be overwhelmed Programs and Services Regional PHPR Teams (4) Hospital Based Epidemiologists & Disaster Epidemiology NC DETECT & NC HAN Biological Agents Registry SNS and other Medical Countermeasures Training and Capabilities Assessments 5

6. 6 NC Public Health Preparedness & Response Epidemiology Section Chief: Megan Davies, MD PHP&R Director: Dr. Julie Casani, MD, MPH Regional Office Staff Planning Consultant, Training and Exercise Coordinator, Industrial Hygienist, Pharmacist, Program Support

7. 7 NC Public Health Preparedness & Response Medical Countermeasures Group State Pharmacist Medical Logistician Program Manager Regional Pharmacists (4) Responsibilities: Provides guidance & technical assistance to partners for mass dispensing to impacted populations Serve as a liaison between the CDC and local jurisdictions to implement the Strategic National Stockpile http://arlingtonva.s3.amazonaws.com/wp-content/uploads/sites/25/2013/12/mrctrainings2.jpg

8. 8 The Strategic National Stockpile Program

9. 9 The Strategic National Stockpile: Purpose Large cache of life-saving medications and medical supplies Supplies available for specific or ill- defined threats Strategically located around the country Capacity sufficient to protect people in several large cities at once Designed to supplement and resupply state and local public health assets Started in 1998 with funds from Congress Managed by the Division of the Strategic National Stockpile (DSNS) within the Centers for Disease Control and Prevention (CDC) 6 billion dollar asset Free to everyone

10. 10 The Strategic National Stockpile: Purpose Includes life-saving medications and medical supplies for: Chemical, biological, radiological threats Category A biological threats- pose highest risk to public health and national security Smallpox Anthrax Botulism Plague Tularemia Viral Hemorrhagic Fevers

11. 11 The Strategic National Stockpile Pharmaceuticals Radiation countermeasures Antibiotics (oral & IV) Nerve agent antidotes Vaccines and anti-toxins Antivirals Medical Supplies IV Administration Airway Management Wound Care Burn& Blast Care Personal Protective Equipment (PPE) Bottom images available from Push Package Catalog 2.01.2012 http://www.iaff.org/ET/Smallpox/PHIL_2674_lores.jpghttps://chemm.nlm.nih.gov/chempack.htm

12. 12 Receiving, Distributing, and Dispensing Strategic National Stockpile Assets: A Guide to Preparedness, Version 11

13. 13 The Strategic National Stockpile Components Include: 12 hour Push Package Managed Inventory ChemPack Federal Medical Stations Additional SNS Programs Federal Purchasing Power Stockpile Services Advance Group (SSAG) Cities Readiness Initiative

14. SNS Components 12-hour Push Package 12 push-packages housed in 10 undisclosed locations First Line of Support: Broad spectrum for Ill-defined threat Delivered within 12 hours to the state Consist of 130 containers, weighs 50 tons Use world-class transport partners Fits into a wide-body cargo aircraft Contents: 500,000 10-day oral antibiotic regimens IV antibiotics and supplies Respiratory medications and supplies Pediatric supplies Medical/Surgical supplies 14

15. SNS Components Managed Inventory Stored and maintained by DSNS or commercial partners Also strategically located Used as additional supply to the PP or in response to a specified threat Represents 97% of SNS assets Delivered within 24-36 hours to the state 15

16. 16 SNS Components ChemPack Prepositioning of chemical agent antidotes 1300 ChemPack containers across the US 57 containers with a 454 person capacity located in 43 hospitals in NC Ensure availability to state and local emergency responders Allows for immediate response to a large-scale chemical exposure Federal Medical Station 250 bed mobile hospital Parceled 50 bed units 3 day supply of pharmaceuticals, equipment, and supplies Requires site, staffing and set-up from the jurisdiction Receiving, Distributing, and Dispensing Strategic National Stockpile Assets: A Guide to Preparedness, Version 11

17. 17 Additional SNS Programs Federal Purchasing Power Defense Logistics Agency Variety of item and transportation vendors Possibly longer response time Subject to market availability SSAG Specialized group of responders Can be deployed with the SNS Provide expertise on SNS assets & incoming supplies Can request additional supplies if needed http://www.etbrooking.com/portfolio-items/finding-efficiencies- business-defense-reducing-fuel-cost-defense-logistics-agency/

18. 18 Additional SNS Programs Cities Readiness Initiative Goal is to enhance preparedness in large population centers Local health departments develop and implement plans to dispense antibiotics to the entire population within 48 hours Originally based upon worst- case scenario of a large scale anthrax attack East state has at least one CRI Region NC CRI Region is Charlotte/Mecklenburg Image modified from http://epi.publichealth.nc.gov/phpr/regions.html

19. 19 Request for SNS Assets When is requesting SNS assets justified? When an incident impacts a local jurisdiction and has the potential to overwhelm available local resources Scenario Overt release Claim of release or possible attack Supported by intelligence/law enforcement Laboratory confirmation Unexplained increases EMS requests Use of antibiotics/non-prescription products ED surveillance and other epidemiological indicators Evidence of Pandemic Influenza

20. 20 SNS Deployments Medication and Supplies: New York City 9/11 Attacks and the Anthrax Attacks, 2001 Gulf Coast after Hurricane Katrina, 2005 H1N1 Response, 2009 FMS Modules: Katrina, 2005 Rita Dean Gustav Ike Isaac North Dakota Floods, 2009 & 2010 Totals more than 14,000 beds http://thelede.blogs.nytimes.com/2008/08/13/daschle-is-persuaded-on-the- anthrax-case/?_r=0 http://www.thenation.com/article/august-29-2005-hurricane-katrina-strikes-the- gulf-coast/

21. 21 SNS Program Oversight DSNS’s Mission: to prepare and support partners and provide the right material at the right time to secure the nation’s health Operates & maintains the Strategic National Stockpile (SNS) Collaborates with federal partners to ensure appropriate medical countermeasures are available for a variety of public health threats Coordinates with partners to encourage integrated response planning between public health, healthcare and emergency management Ensures rapid delivery of countermeasures to an affected area Provides technical assistance and guidance pertaining to receiving, distributing, and dispensing medical countermeasures

22. 22 Requesting, Receiving, Distributing, and Dispensing the SNS

23. 23 Overview- Request, Receipt, Distribution, and Dispensing SNS Assets Public Health Threat Local Health Department Use Available Local Supplies Will the threat potentially exhaust local supplies?

24. 24 Overview- Request, Receipt, Distribution, and Dispensing SNS Assets County EM Submits SNS Request NC SPARTA Received by State EM Yes, the threat will likely exhaust local supplies.

25. 25 Overview- Request, Receipt, Distribution, and Dispensing SNS Assets Request Reviewed by SERT Resources Available Deployed to County LRS Are supplies available from traditional resources? Yes Public Health: LRS is a Local Receiving Site

26. 26 Overview- Request, Receipt, Distribution, and Dispensing SNS Assets Request Reviewed by SERT Resources Unavailable EM Director Submits Request to CDC Are supplies available from traditional resources? No

27. 27 Overview- Request, Receipt, Distribution, and Dispensing SNS Assets Request Reviewed by CDC/ Federal Partners Request Approved Requested SNS Assets Deployed Will SNS Assets Deployed? If yes….

28. 28 Overview- Request, Receipt, Distribution, and Dispensing SNS Assets Assets Transported to RSS Assets Repackaged per County Request Assets Shipped to County LRS Public Health: Receipt, Stage, & Storage Site Assets Deployed to Affected County

29. 29 Overview- Request, Receipt, Distribution, and Dispensing SNS Assets LRS Repackages Supplies for Dispensing Sites Assets Transported to Local PODs Public/Patients Receive Countermeasures Public Health: PODs are Points of Dispensing EM: PODs are Points of Distribution When assets are within 24 hours of being depleted and still needed, the request process is repeated. Getting Assets to the People

30. 30 Requesting SNS Assets Local EM’s Role: Coordinate with health department and activate EOC Assists with decision to request SNS resources Submits request to state emergency management Local Health Department’s Role Activation and set-up of LRS, POD(s), staff, partners PHPR’s Role: SERT reviews request State EM Overall coordination of response and recovery programs by implementing the NCEOP as directed by the Governor State EM Director submits request to the CDC

31. 31 Requesting SNS Assets What information is needed for the request? Description of situation Status of and specimen testing Target population, including estimated numbers of population who will receive medical countermeasures Quarantine measures taken Relevant local SNS plan information LRS location Number of PODs Number of residents Number of first responders Internal capabilities Items needed

32. 32 Receiving SNS Assets State EM’s Role: State EOC is activated (Level 4) when it is determined NC will receive assets Notify transportation companies and law enforcement PHPR’s Role: Prepare and activate RSS Coordinate repackaging of SNS assets Local Health Department and EM: Logistics Resources Staffing, volunteers Operations NC Eagle Down Exercise, 2012

33. Distributing SNS Assets State EM’s Role: Maintains transport portion of SNS Plan Contracts Routing Security NCEM will notify NCSHP to enact the RSS transportation security plan PHPR’s Role: Coordinate distribution of assets to county Local Health Department Repackage and distribute assets to PODs Local EM: Can coordinate secure transport or perform escort of assets to LRS/POD 33 NC Eagle Down Exercise, 2012

34. 34 Dispensing SNS Assets Local Health Department’s Role Provide medication to their entire population as quickly as possible Local EM: Coordination of external partners as requested for staffing and equipment for example American Red Cross Communications Law Enforcement EMS Partners Behavioral Health Management EOC Requesting SNS Resupply when less that a 24- hour supply remains Cleveland County, Dust in the CRI Wind Exercise, 2015

35. 35 NC’s H1N1 Response in 2009

36. 36 H1N1 Response What actually happened.... Request process not used-CDC “Pushed” supplies to states State EOC Activated Shipments April/May 2009- Antivirals and PPE 214 orders total to 86 sites October 2009 Tamiflu suspension sent from private warehouse to local health departments N95s 214 orders to 86 sites RSS opened November 2009 Tamiflu suspension sent from private warehouse to local health departments

37. 37 H1N1 Response What actually happened.... Transportation Plan utilized Security Plan utilized Amounts of supplies received More than 20 tractor trailer loads total Antivirals Approximately 300,000 regimens PPE Over 6 million N95s Gowns, gloves, and surgical masks also received Most counties received supplies at health department

38. Summary Overview of NC Public Health Preparedness & Response CDC’s Strategic National Stockpile Program (SNS) Purpose Components Requesting Assets Deployments Program Oversight Requesting, Receiving, Distributing, and Dispensing the SNS State Emergency Management’s Role Local Emergency Management’s Role Local Health Department’s and PHP&R’s Role NC’s H1N1 Response in 2009 38

39. 39 Thank you Local and State EM- Public Health could not do this without you!

40. References 40 1. North Carolina Epidemiology. http://epi.publichealth.nc.gov/about.htmlhttp://epi.publichealth.nc.gov/about.html 2. North Carolina Public Health Preparedness & Response. http://epi.publichealth.nc.gov/phpr/http://epi.publichealth.nc.gov/phpr/ 3. NC PHPR/Strategic National Stockpile. http://epi.publichealth.nc.gov/phpr/sns.htmlhttp://epi.publichealth.nc.gov/phpr/sns.html 4. Office of Public Health Preparedness and Response: Division of the Strategic National Stockpile Fact Sheet. http://www.cdc.gov/phpr/documents/dsns_fact_sheet.pdfhttp://www.cdc.gov/phpr/documents/dsns_fact_sheet.pdf 5. Public Health Emergency Medical Countermeasure Enterprise. http://www.phe.gov/Preparedness/mcm/phemce/Pages/default.aspx 6. SNS Push Package Catalog; February 1, 2012 7. Receiving, Distributing, and Dispensing Strategic National Stockpile Assets: A Guide to Preparedness, Version 11.

41. 41 Questions