0. Countermeasures and Emergency Management Considerations
4/21/2017
Countermeasures and Emergency Management Considerations
Matthew Minson, MD
OPSP/ASPR/OS/USDHHS

1. 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

2. In general the threat consideration is substantial
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

3. Anthrax Exposure: Proportion of Population Saved
4/21/2017
Anthrax Exposure: Proportion of Population Saved
DELAY in Initiation
DURATION
of Campaign
Immed.
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%
This model was developed by Dr. Nathaniel Hupert of Weil Medical College at Cornell. It shows how delays in either detection (initiation of a campaign) or the amount of time it takes to provide antibiotics to a population will translate in lives lost in persons exposed to anthrax.
For example, if the entire population of your city was exposed to anthrax released in the air, if it took 2 days to identify the exposure and 5 days to get antibiotics to the entire population, 8% of those exposed would die. [Note to presenter: use the actual population figures for the city to calculate the potential number of deaths.]
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%

4. 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

5. CRI MSA Tables
Table I
Combined 36 cities from CRI
Table II
36 planning cities for 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

6. Countermeasure Cascade: Generic
FED
SNS
PUSH PACKAGE, MI
STATE
Receiving Staging Storing
L. Dist. Center
pod F S L
Locals

7. 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

8. assumptions Model Staff per shift per POD Staff Campaign staff
4/21/2017
Medical PODs
Non-Medical PODs
Target Population
1,000,000
PEP duration
2 days
9 days
Hours of operation
24 hr/day
Number of shifts
2 shifts
Patient throughput
500 pts/hr/POD
2,000 pts/hr/POD
Number of PODs 42 10 11
Core: Public health 19 2
Core: Non-public health 33 48
Support staff 13
Total 65 60 44 5 76
110 30 23
150
138
1,821
434
3,162
753
1,150
1,246
297
240
6,229
1,484
1,438
assumptions
Model
Staff
per shift
per POD
Staff
Campaign staff

10. Countermeasures: PODS

11. Medical PODs vs. Non-Medical PODs
4/21/2017
Medical PODs vs. Non-Medical PODs
Medical PODs
Non-Medical PODs
Target Population
1,000,000
PEP duration
2 days
Hours of operation
24 hr/day
Number of 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 44 5 76
110 30 23
150
138
1,821
3,162
1,150
1,246
240
6,229
1,438
assumptions
Model
Staff
per shift
per POD
Staff
Campaign staff

12. CRI Challenges/Issues
Staffing (Volunteer)
State/Local Leadership
Resistance to Planning (Difficult)
Security Resources
Assessment Process
Population Dynamics (Cooperation)
Untried Scenario (Battle Conditions)

13. 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

14. Countermeasures
USPS STRIKE

15. 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

16. 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.

17. HOME STOCKPILING MEDKIT
Countermeasures
HOME STOCKPILING
MEDKIT

18. 97% efficacy First Responders, Clinic, Corporate
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

19. CRI MEDKIT

20. 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

21. Medkit (Home Antibiotic Kits) USPS (HHS Lead) EUA
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

22. 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

23. Countermeasure Delivery
RECENT DEVELOPMENTS

24. 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.

25. 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

26. 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

27. 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)

28. PH SUMMIT Countermeasures Strategy
Continued issues
Worker protection
Medkit
POD EUA
Communications Strategies
Increased interest and Federal amplification of USPS option (BARDA Modeling Conclusion)

29. Countermeasures
The Future

30. Countermeasures
QUESTIONS?