In June, responding to the continuing international spread of the Influenza A H1N1 flu outbreak, the World Health Organization (WHO) raised the global pandemic alert warning system to its highest level, Phase 6 – which indicates that the human-to-human transmission and ongoing community-level H1N1outbreaks have been confirmed and are now worldwide. The WHO announcement was intended to signal public-health officials in every country in the world to step up their efforts in dealing with the disease. By then, many U.S. states had been affected, making it necessary to execute emergency-response plans that had been in place and exercised for years.
H1N1 is both widespread and emergent, but the responses required are beyond the day-to-day capabilities of the medical community of any nation. In the United States, a Strategic National Stockpile (SNS) was created to deal with just this type of situation. The SNS is a federally controlled cache of vaccines, pharmaceuticals, and other medical supplies and equipment that can be activated in the event of a national emergency. The stockpile represents both a real – i.e., material – asset in a federal warehouse and a virtual VMI (Vendor Manager Inventory) asset. In SNS terms, VMI represents additional production capacity that can be quickly activated to meet the country’s needs during a crisis.
The SNS is managed, and the vaccines and pharmaceuticals distributed, by the U.S. Centers for Disease Control & Prevention (CDC). When the deployment and distribution of vaccines, pharmaceuticals, and/or other medical supplies is necessary, the CDC pushes critical inventory from the SNS to the states needing those supplies. Potentially that could mean all 50 states – more when U.S. territories are included – but it is usually far fewer because most threats to public health tend to be regionalized. The states in turn pass the inventory items to the local level – an umbrella term that includes counties, cities or towns, hospitals, and clinics. In turn, the public-health working professionals on the front line dispense the supplies to individual patients – here the potential number could be in the tens of thousands.
In its fight against H1N1, the CDC authorized the shipment of 25 percent of the SNS medical-materials inventory to those states with already documented H1N1 cases. Following this action on the part of the federal government, many states – Ohio and Tennessee are among the most prominent examples – recently put their own SNS distribution strategies (planned from the tabletop, tested, optimized by implementing the lessons learned, and worked out in full-scale disaster-preparedness exercises) to the ultimate real-world test.
Needed: A Faster and More Flexible Multipurpose System In the first few years following the creation and gradual buildup of the SNS, Ohio and Tennessee, like many other states, used a flat-file spreadsheet to keep an inventory of: (a) the state-owned materials already on hand; and (b) those provided by the CDC. The principal advantages of this system were the ease with which the file could be created and the speed with which it could be used locally. The principal disadvantage was that it worked only on a small scale: Only one person at a time could use the information available.
Prior to actually having to use the SNS in a real-life situation, both Ohio and Tennessee looked for a better system that could store the data centrally so that many users could access it at the same time. With a system of that type available, an emergency manager could view up-to-the-moment data and use it in his or her decision making. Moreover, the personnel assigned to handle the SNS shipments could incorporate shipping and receiving data in near to real-time. (Here it should be noted that, after federal SNS assets are deployed, they become state assets, and the states would then have total responsibility for inventory accuracy and control over the materials acquired from the national stockpile.)
Although there are a number of commercial products and systems available for the purpose of inventory management, few are intended to support SNS distribution requirements. Ohio and Tennessee selected a commercial inventory-control software platform – called the Inventory Resource Management System (IRMS) – that uses a module designed specifically for SNS distribution. Developed by Upp Technology Inc., IRMS is based on a warehouse inventory-control platform that allows states to use the software not only in their day-to-day warehouse and storage operations but also, in an emergency or crisis situation, to receive, stage, store, and track inventory received from the SNS.
The Ohio plan calls for distribution from the CDC to a central RSS (receive, stage, and store) warehouse. Materials taken from the RSS are apportioned to eight distribution nodes strategically prepositioned throughout the state; the node locations are based on the population in a specific geographic area and the weather conditions there, topographical data, and other relevant information both on the ground and projected for the future. There is considerable flexibility built into the plan, moreover. For example, if the population of one affected county had increased significantly since the initial system setup, state officials could use the IRMS software to quickly recalculate the SNS apportionments planned for that county.
At the node itself, the materials shipped from the RSS warehouse are again apportioned (to a county or hospital level) and can be shipped out immediately. Ohio uses a three-person “picking team” to assemble an order for shipping: An inventory controller scans the material into the inventory database (wirelessly, and in real time); a picker picks the material from its SNS storage space; and a packer first confirms that the item is the correct one needed and then places it on the pallet being prepared. A separate quality-control process then confirms the order and applies a color-coded label, indicating the destination, to the pallet.
In combating H1N1, a decision was made at the governor’s level to distribute the materials only as far as the node level and hold them there, thus eliminating the initial order fulfillment and shipping tasks. Holding the materials at the node obviously allows greater control. However, moving the materials from the RSS to the node ensures that the RSS itself is now ready to accept another 25 percent shipment from the CDC without delay. Shipping materials beyond the nodes to local users would be triggered by the exhaustion of commercially available materials on hand. Fortunately, this situation has not yet occurred.
Quantity, Quality, and Other Mandatory Virtues In any event, the bottom line is that Ohio is now ready. And it is likely to stay ready, for the simple reason that, as Mark Keeler, the Ohio Department of Health’s State SNS Coordinator, commented, “The biggest thing you can do with any system is train regularly.”
Just as emergency-response agencies have tools that allow them to respond effectively, commercial warehouses have software and plans that improve their own efficiency and level of awareness. Warehousing is not just a simple matter of putting things on and taking things off trucks. There is a well defined process in place: When new inventory arrives it must be counted and recorded, stored, and tracked; as need isentified, orders are assembled and verified for fulfillment; and as they are packaged for shipping, pallets are documented in considerable detail and made ready for delivery.
Whether in the commercial warehouse, or in the state RSS warehouse facility used by the Ohio Department of Health (ODH) in an emergency-response situation (such as that dictated by the H1N1 pandemic), getting the right material to the right place, on time – and in sufficient quantity and quality – is what matters most, particularly when those materials are items such as anti-viral medications and personal protective equipment. N-95 masks, for example, which are certified by the CDC’s National Institute of Occupational Safety and Health (NIOSH) as being able to block 95 percent of particles less than 0.3 microns in size (the standard for responders to a virus-based threat).
In Ohio, several state agencies provide professional staff for the RSS warehouse. Those staff members, augmented by department of health staff, are both the on-site subject-matter experts in warehousing as well as the equipment operators. During a public-health emergency, Ohio’s partnership with the RSS warehouse frees up the ODH’s frontline disaster-response personnel for deployment in clinical, laboratory, and epidemiological settings where their skills may be used both more efficiently and more effectively. The assignment of highly qualified professional staff to warehouse operations also decreases both the likelihood of inventory loss through breakage and the possible loss of staff members through injury.
Testing the System – and the Fortitude of Participants The Ohio Department of Health, together with other state agencies, conducts a full-scale exercise of the state’s distribution system every year. Few if any exercises, however, could come close to reality in terms of scale, in pressure, and in stressing the system as the H1N1 outbreak did. In a very real sense, therefore, the SNS deployment made necessary by the real-life H1N1pandemic has been the best full-scale run-through of the SNS process that could be conceived, testing both the timing of deliveries and the accuracy of inventory management – but without a wide-scale loss of life.
Having had a real-life event to test and evaluate the state’s emergency response and preparedness software and plans, Ohio plans to test only two components of the system this year: (a) the process used by the state to request additional materials from the CDC; and (b) the processes used by local officials to request the materials from the state. None of these processes was needed during the H1N1 outbreak.
As in Ohio, Tennessee’s SNS distribution plan uses a regional system for command, and for the communication of requests, that relies on a single point-of-contact model. In Ohio, local health agencies make requests through their emergency-management agencies, which in turn pass the request to the state emergency management agency, which passes it to the ODH. In contrast, Tennessee operates a central state health operations center, which receives orders and reports from regional health operations centers, which use a single point of contact for ordering materials.
The systems in both states funnel orders to singular phone numbers, e-mail addresses, and fax numbers. Using multiple points of contact creates a consistent risk of some orders being recorded for the same singular need. During a disaster this could cause the waste of vital resources. In addition, using software without this discipline requires updating phone contacts (and other information) as shifts change in the operations center and in the other levels of the system.
Despite its somewhat different approach, Tennessee, too, is ready.
The Super-Bowl Philosophy – in Real-Life Emergencies Vince Lombardi preached that, “If you practice the way you play, there should not be any difference.” In accordance with this philosophy, he trained his football teams as hard as he expected them to play on game day. Dr. Paul Petersen, the SNS coordinator for the Tennessee Department of Health, carries the same philosophy to the next level by postulating that there is no special level of play required for what might be called “the big game.” This approach is somewhat different from Ohio’s way of thinking, but has been no less effective.
To Dr. Petersen, having a special plan in place for disaster distribution virtually guarantees that only a select few will know of the plan, and of the system designed to use it, when it matters most. For that reason, Tennessee decided to use an operational warehouse that had the material-handling equipment, warehouse personnel, and transportation resources readily available. The Tennessee approach allows for efficient distribution and tracking of medical countermeasures shipped throughout the state, using a systematic process already being practiced daily. Partnering with Upp Technologies provides the inventory-management system needed to ensure the accurate allocation and record-keeping of state assets.
The Tennessee DOH has acquired and successfully tested the skills it needs to receive, inventory, and ship SNS assets in an emergency. The state’s future goal is to implement IRMS as an all-hazard solution for emergency-response inventory management and patient tracking as well as the carrying out of these same functions day-to-day in the state’s health departments. By exercising the plan daily, it becomes embedded in muscle memory, and the public health and warehouse staff need only act on what has already become an almost routine situation.
When thinking about a response to a large-scale outbreak of disease – and/or coping with another incident that taxes state and local medical-community planners – public-health officials must consider the SNS and how this federal asset will be controlled, distributed, and secured at the state level. Not only because it is the responsibility of those who receive it but also, and of much greater importance, because it could be the difference between the success or failure of the overall response effort.
Joseph Cahill is the director of medicolegal investigations for the Massachusetts Office of the Chief Medical Examiner. He previously served as exercise and training coordinator for the Massachusetts Department of Public Health and as emergency planner in the Westchester County (N.Y.) Office of Emergency Management. He also served for five years as citywide advanced life support (ALS) coordinator for the FDNY – Bureau of EMS. Before that, he was the department’s Division 6 ALS coordinator, covering the South Bronx and Harlem. He also served on the faculty of the Westchester County Community College’s paramedic program and has been a frequent guest lecturer for the U.S. Secret Service, the FDNY EMS Academy, and Montefiore Hospital.