1. Medical Countermeasures Program Overview
Emergency Preparedness Taskforce
2019
Today we are going to take a look at the West Virginia Medical Countermeasures program. We are going to look at the program as a whole and what it does as well as discuss some changes that are coming about.

2. Medical Countermeasures Operations
The MCM Operations is a huge undertaking for the state, regional and local jurisdictions. Although there are plans in place that have been exercised as table tops and full scale, there has never been a need to have a full activation of the system here. The operations can be complex and requires a large amount of cooperation and communication between all partners involved.

3. When disaster strikes
West Virginia is no stranger to disaster. We have seen hundreds of natural and man made disasters over the years from floods and snow storms to the derecho and train wrecks. We have not seen an emerging infectious disease outbreak, epidemic of large proportion or a pandemic. Each local health department and the state are required to maintain an up-to-date all hazards plan that prepares us for these types of disasters and provides a mechanism for mitigation.

4. How to activate the Strategic National Stockpile
There may come a time that something truly catastrophic happens in our state that exhausts all available local, regional and state assets. Should this happen, the Centers for Disease Control and Prevention (the CDC) has stockpiled medication and supplies at locations around the country to assist us. We will take a look at what they have to offer and how long it will take to get these things later in the presentation. For now, lets see what it takes to get these materials.
Once a threat has been identified locally, regionally or state wide, there is a confirmation process that takes place between local epidemiologists and the states epidemiologists. When the confirmation is made and passed on to the Center for Threat Preparedness (Health Command), Health Command will engage our partners state wide and advise the State Health Officer. The State Health Officer will address the Governor and the Governor will make the request for assets to the CDC.
There are many steps in this process, but, if we follow the plan and communicate well, the process will be quick and efficient.

5. What does the CDC do next?
The CDC keeps these stockpiled materials categorized for rapid deployment. The initial shipment of materiel was once referred to as the 12 hour push pack based on the time expected for the materiel to arrive at a Receive, Stage and Store (or RSS) facility. The name has now been changed to “Push Pack” as it is no longer expected to take 12 hours to reach it’s destination. These materiel’s are pre-inventoried and ready to ship at anytime. They can be placed in trucks or on aircraft and sent rapidly. Under what has been considered in the past as the worst cases scenario, the push pack contains enough prophylaxis for all WV citizens plus 10% (approx. 2.2 million individuals). The push pack will provide the initial 10 day supply of antibiotics.
Other supplies of medication can be sent as Managed Inventory after the initial supply is sent. This usually happens for a smaller population including those directly impacted and those in surrounding areas. The managed inventory supplies people with an additional 50 day supply of antibiotics and if needed the anthrax vaccination.
The push pack is expected to arrive to the RSS facility in about 4 hours.

6. RSS OPERATIONS
When the decision is made to open the RSS location, many things must happen at once. The Center for Threat Preparedness will already have stood up Health Command and the command will begin the operations. A message will be sent out to volunteers to activate the RSS. These people will gather at the RSS location along with the facility management and other partners. Preparation of the facility should begin within 2 hours of the activation ensuring the facility is ready when materiel arrives.
Once the materiel arrives it will be cross docked for the larger amounts and sorted for smaller amounts. The decision to sort this way is based on the population of the area(s) effected. The crossed docked materiel will go straight to another truck and the sorted portions will go into the facility. Once inside the facility the material will be broken down into specific quantities and staged for reload on trucks. All material will be inventoried and assigned to the jurisdictions before being loaded. When reloading the trucks for distribution, the loads will be placed in order of delivery for ease of handling and sent off. All shipments will be tracked and the drivers (and escorts if needed) will be equipped with SIRN radios to report conditions and location as needed.

7. DISTRIBUTION
After all of the material is loaded on a truck, the trucks will begin their routes to the Local Health Departments. Each Health Department will receive their full compliment of medication based on the population reported plus 10% to satisfy any transient individuals. Additional material will be staged at the RSS location for distribution as needed.
It will take up to 4 hours for the RSS location to turn around material and have it moving towards the Health Departments. With this turn around, we are still under the original receive time for the 12 hour push packs of the past. Trucks will begin arriving as soon as possible based on the time it takes to get to the first stop. We will factor in the times and report them to the Health Departments so they may be prepared.

8. What’s next?
Material will be shipped directly to the Local Health Departments in the effected areas. Once it arrives, it will need to be unloaded, inventoried and sent out to the Points Of Dispensing (POD) locations. There are two different types of POD’s.
The first is an Open POD. This type of POD is typically managed by the health department and is open to all members of the public. This is going to be the highest volume type and will need the greatest number of people to facilitate. The open POD can be run in several ways including a walk-in and drive through style. Depending on the type of operation you are doing there are many considerations that need to be made including space available, flow of people, number of people, throughput and time to complete to name a few.
The second type is the Closed POD. This style normally caters to a select group of people and will be limited in the time it takes to complete. A local business many want to participate as a closed POD to prophylax their staff and family members. This is normally done under a memorandum of understanding that outlines the POD operation and the population being served. These people can then be accounted for without having to go through an open POD. Typically closed POD operations include them coming to the Health Department to get there share of the medication. Please be sure to inventory what you give them and what they return to you in the end.

9. WHEN THE INCIDENT IS OVER
There is a chance that the CDC will want the state to return any unused portions of the SNS we have. This is information will be made know to us during the operation. Should the CDC request the return of goods, you must have a plan to send the material back to the RSS location. Your plan will need to include receiving any used portions from the closed POD’s.
We will be discussing the inventory management system towards the end of the presentation.

10. What is available from the SNS
The CDC maintains a stockpile of Medical/Surgical supplies as well as medications. They even have mobile treatment centers in a box called “Field Medical Stations” that can be deployed in hours and help to treat hundreds of patients.
Most of us are aware of some of the medications available to us like Doxycycline and Cipro. In fact they also stock Gentamicin, Amoxicillin, Penicillin, Vancomycin and Clindamycin to name a few. They have pills and suspensions available for most treatments. They carry a number of radiation treatments depending on the type of exposure. They have supplies for burn/blast victims. Nerve agents are made available in the stockpile as well as the ChemPack program that we will talk about shortly. They even keep a number of controlled and non-controlled emergency medications at the ready for request.
They have a generous number of ventilators, suction machines and I.V. equipment for use.

11. Cities Readiness Initiative (CRI)
CDC’s Cities Readiness Initiative (CRI) is a federally funded program designed to enhance preparedness in the nation’s largest population centers, where nearly 60% of the population resides, to effectively respond to large public health emergencies needing life-saving medicines and medical supplies. State and large metropolitan public health departments use CRI funding to develop, test, and maintain plans to quickly receive medical countermeasures from the Strategic National Stockpile and distribute them to local communities.

12. CRI COUNTIES
In West Virginia there are 4 CRI Counties broken into two different Metropolitan Statistical Areas (MSA). These counties were selected by the Office of Budget Management and are adjusted as they see fit. No jurisdiction can opt-into the program and those selected can not opt-out. As you can see from the map, the CDC has broken the country down in regions to identify states and jurisdictions. Although the original plan was to include only the largest jurisdictions and account for 60% of the countries population, decisions made afterwards included at least one city from each state.
Kanawha, Clay and Boone Counties are all part of the Charleston MSA and are recognized as part of the CRI. Jefferson County is also a CRI and part of the National Capitol Region MSA. These counties have all the same reporting requirements as other counties in the state. They have additional reporting and exercise requirements that must be met annually or on a rotating basis. Each of these counties must also have an Operational Readiness Review done every three years with the results reported to the CDC. So far this year, we have completed two of the four reviews.

13. ChemPack
The mission of ChemPack is to provide, monitor and maintain a nationwide program for the forward placement of nerve agent antidotes. To provide state and local governments a sustainable resource; and improve their capability to respond quickly to a nerve agent incident. The SNS has up to a 12-hour response time, too long in the event of a chemical attack. State and local governments have limited or no chemical/nerve agent antidote stocks. Hospitals carry very limited supplies of treatments for nerve agent exposures. Nerve agent antidotes are costly and have variable shelf lives (not an easily sustainable resource). Benefits of the ChemPack program include Pre-position containers for faster response times during an emergency, extended shelf life of SNS-owned assets to save in overall costs, local control of critical life-saving assets to ensure assets are dispensed in a timely fashion and federal management of product life cycle to ensure quality of products.

14. ChemPack
The ChemPack Program supplies materiel, approved storage containers and monitoring equipment. Project Areas are required to provide secure, environmentally controlled storage areas with phone connectivity. The Program monitors temperature and container entry 24/7. Project Areas are required to sign a Memorandum of Agreement to store and use materiel according to program guidelines
CHEMPACK containers are self-contained units placed in centralized locations to enable first responders to quickly administer life-saving antidotes and save lives. There are two types of containers:
EMS containers
Geared to first responders
85% auto injectors
454 casualty capacity
Hospital containers
Geared to clinical care environment
85% Multi-dose vials
1,000 casualty capacity
*There are 12 locations across our state that house these containers. We have multiple partners and are gaining more as time goes on. We are confident in our plan to deploy these medications and can have them anywhere in the state within 90 minutes.*

15. Changes are coming!
As many of you may be aware, the CDC’s Division of State and Local Readiness control of the SNS has been moved to ASPR. ASPR is the Office of the Assistant Secretary for Preparedness and Response. They are a division of the U.S. Department of Health and Human Services.
Although we were initially told that the October change over would have no bearing on the states, we have since found out otherwise. Information coming from ASPR has been very slow and not always accurate. Here are a couple things we are sure of. The ChemPack program has left CDC and gone to ASPR. Although there was some manpower and financial issues that needed to be resolved, they seem to be on track and are moving forward. The SNS program is much slower to come around. There have been a lot of unanswered questions.
What has been confirmed is the change from the past practice of “worst case scenario”. Up to now, the CDC looked at the worst case scenario as an Aerosolized Anthrax attack and had all jurisdictions preparing for this. ASPR is planning to change this. They have confirmed already that they will be moving away from this scenario and expecting preparedness to move around an Emerging Infectious Disease (EID) scenario. More specifically, they are leaning towards Pandemic Influenza (Pan Flu).
As a result of this change, new plans will need to be made and exercised along these lines. There will be no reason to scrap the current Anthrax plans as they are still valuable in their own right. Fortunately we here in WV are already a few steps ahead of other states when it comes to Pan Flu preparation. WV has seen its share of influenza over the years and most Health Departments are well versed on Flu clinics. As such, planning will need to move these clinics to a POD style presentation and be able to account for more patients. This will also mean more volunteers and more credentialed providers to deliver the required vaccination. It might be a good time for administrators and Threat Preparedness Coordinators to get together with local hospitals, clinics and providers to see if they can enlist their support. This may mean more Closed POD’s or getting staff to your open POD’s.

16. Changes are coming!
I mentioned in an earlier slide that we would discuss inventory management toward the end of the presentation. As I have spoken to many local health department representatives and found that most departments do not have a program for inventory management. Most indicated that they will use a spreadsheet for logging receipt of, distribution of and administration of medications from the SNS. Although I do not have issue with this being done, there is a better way to do this.
The state has in the past done the same thing. Then we purchased an inventory management program that would track any item we have stockpiled. This system is great and works well. However, it is not compatible with the CDC’s system. We are not able to communicate the information back to the CDC in a format that their system can translate. So, we have decided to explore the use of IMATS. IMATS is the CDC owned and maintained Inventory Management and Tracking System. The CDC has offered this system and their support to us at no cost. We will simply need to manage the user accounts and import/export data. By getting on board with this system, we are compliant with the CDC guidelines, grant deliverables and will have a statewide network for tracking assets.
CTP completed it’s first successful test of the IMATS system last month and we will be looking into a roll-out plan this year.

17. Questions?
Does any one have any questions about the information I have presented?
Please feel free to call on me anytime with questions or if there is something I can help you with.