Emergency managers are working hard, on a continuing basis, to improve and support the national capability to assist in providing assets to affected areas during an extreme biological incident or emergency requiring medical countermeasures. The U.S. Centers for Disease Control and Prevention (CDC) leads this effort and recently reformulated what are called the “12-hour push packages” – assets designed to provide immediate help on a broad spectrum of potentially beneficial interventions urgently needed in the early hours of an emergency, even when information on the extent and content is incomplete.
CDC, in consultation and collaboration with state and local emergency managers, has already increased the number of storage locations available, enhancing the quality and speed of distribution across the country. The ability to distribute large quantities of medicines and other countermeasure resources in a very short window of time, to communities throughout the nation, is evolving from a possibility to a likelihood and will soon become a certainty. The growing partnership between CDC and local emergency managers continues to dramatically shorten the crucial time window even further.
Transferring and transporting medical products to the people who need them most during an emergency depends in large part on: (a) the building of a capable infrastructure; and (b) advance planning at the state and local levels not only county by county but even neighborhood by neighborhood. That is why CDC now stockpiles and delivers medical countermeasure assets to support its partners at all levels of government. It also is why state and local emergency managers are working to develop and refine their own abilities to effectively receive and use the assets provided. All partners in the supply chain are focused particularly on delivery and disbursement.
Difficult Challenges & Best Practices
One profound challenge facing all responders involves the shelf-life extension of medical resources. The Department of Defense has initiated a special Shelf Life Extension Program (SLEP) and is partnering with states and lower jurisdictions to meet this challenge. In fact, many state and local governments have already purchased and are storing antivirals and antibiotics as countermeasures against bio-terrorism attacks. These stockpiles are typically designed both to ensure early access for first responders and to provide critical-infrastructure personnel the resources they need to carry out the initial response actions required to deal with sudden disasters and other emergencies throughout the entire country.
Fortunately, the Baltimore (Md.) Department of Homeland Security’s Urban Area Security Initiative (UASI) has already provided a helpful best-practice example of how this upgraded approach works. Several years ago, the City of Baltimore and several surrounding counties purchased stockpiles of ciprofloxacin and doxycycline for use not only by regional responders but also by an estimated 106,000 other responders from the area’s fire services, emergency medical services, emergency managers, law enforcement, and public safety communities. By doing so, the City and the responders combined their efforts to take the absolutely mandatory steps needed to ensure the safety and security of the items stored, complying not only with manufacturer humidity and temperature requirements but also federally mandated FDA (Food and Drug Administration) guidelines. It is estimated that, to stay current and effective without the SLEP, the Baltimore UASI would have had to turn over its stockpile every two to three years – at an estimated replacement cost of $500,000 per turnover cycle.
The CDC also is exploring several innovative ways to dispense countermeasures more quickly to local communities by, among other things, cultivating strong collaborative partnerships between and among planners, emergency managers and responders, and even businesses at the state and local levels. CDC provides the funding needed through what are called Public Health Emergency Preparedness cooperative agreements – augmented and supported by technical assistance, pre-approved distribution plans, and performance measurement consultations.
Outreach Programs & Multiagency Partnerships
The technical assistance provided to state and local partners includes significant input from state health department outreach programs. That input includes but is not limited to the following: information related to receiving and dispensing medical assets; on-site and video teleconference consultations; support for various training and exercise programs, including national training summits; and the tools needed to design and test response plans.
The national partnership with state and local jurisdictions and operational personnel has evolved over time not only through the provision of much-needed guidance, assistance, and other support but also through the recognition of changing needs and the opportunities provided by new discoveries. The end result is a significant increase in the availability and use of direct on-site technical assistance to jurisdictions both large and small – again, at all levels of government. That assistance ranges from the interpretation of guidelines to the development and refining of plans to the conduct of training and exercises to the evaluation of both capabilities and performance. Here it should be noted that the evaluations are developed by the dedicated CDC training, exercise, and response teams who not only conduct a broad spectrum of training exercises in Atlanta, Georgia (where CDC is headquartered), but also provide on-site training and exercise support at many other venues throughout the country.
Most state and local public health responders depend, in varying degrees, on both the implementation of emergency contracts and, in some cases, the mobilization of volunteer workforces to distribute medical countermeasures during an actual operational event or incident. The use of volunteers is in fact increasingly critical to the effective dispensing of medical countermeasures during an incident, and for that reason a number of grant-funded pilot studies have been carried out to examine innovative ways to recruit the number of volunteers needed. All of these functions feed into and support the ongoing development of the capabilities critical to the effective dispensing of medicines and medical countermeasures to the emergency communities of all states and numerous local jurisdictions as well.
Tailor-Made Plans & Improved Information Sharing
Every state has developed and maintains its own unique plans to receive, distribute, and dispense the medical countermeasures stockpiled by the CDC. A common denominator of almost all of these various plans is that they: (a) govern the local infrastructure and supporting government and commercial partnerships at the state and local levels of government; (b) are evaluated and exercised by the stockpile coordinators at the same levels; and (c) are reviewed annually – and to the same standards everywhere in the country.
The CDC also funds and maintains several forums through which promising practices and innovative concepts are shared and discussed by health and emergency staff at all levels of government. In addition, several modeling tools have been developed and are used both to facilitate planning at all of these same levels and to evaluate the plans thus developed and promulgated. This process saves significantly in the scheduling and evaluation of resource-costly drills and exercises.
To evaluate the effectiveness of individual state plans for the use of medical countermeasures, regularly scheduled Technical Assistance Reviews – a quantitative objective tool – are conducted annually to helpentify any remaining gaps in such plans. The principal purpose of these technical assistance and performance measurement consultations is to ensure the continuing availability of the flexible framework needed for the delivery – through partnerships with air and ground transportation providers – of medical countermeasures from a national network of storage locations. Within this framework, it is now possible to determine the optimum combination of location and method of transportation required to support the delivery of medical countermeasures within the specific time frame postulated to cope with an ongoing emergency situation.
During the 2009-2010 H1N1 influenza pandemic response operations, many helpful lessons were learned when antiviral drugs and personal protective equipment were needed both to minimize overall illness and the number of deaths. CDC rapidly deployed large quantities of key medical assets, including 11 million regimens of antiviral drugs as well as the personal protective equipment needed by states, tribes, and territories throughout the nation. In addition, the CDC released 300,000 bottles of Tamiflu® for pediatric use – both to compensate for production gaps and to meet the increase in demand – plus 234,000 additional bottles of the suspension.
Meanwhile, the U.S. Department of Health and Human Services (HHS) was authorizing the release, to those same jurisdictions, of 59.5 million respirators. The end result was that, despite a few “close calls,” the timelines set forth in the plans developed at all levels of government were in fact achieved.
The lessons learned from the H1N1 response, and other potential disasters, are regularly and routinely applied to other crises and emergency situations occurring anywhere in the country. To cite but one example, California relied on its own extensive public health preparedness, planning, and training programs to respond to an outbreak of whooping cough in 2010. Immediately after that outbreak had been evaluated andentified, the California Department of Public Health not only offered free vaccines but also encouraged hospitals and local health departments to support the vaccination of new mothers and newborn caregivers. Meanwhile, county public health departments across the state, among the most proactive in the country, applied their own planning and public health preparedness experience to develop and disseminate the educational materials and clinical guidance needed.
These and other prompt actions not only helped raise community awareness but also led to the designation of accessible and innovative vaccine dispensing points – including the assignment of mobile clinics to grocery stores – to reach all communities throughout the state that needed immediate and continuing assistance.
Kay C. Goss
Kay Goss is the President of World Disaster Management, LLC. Her emergency management work began 40 years ago, as senior assistant to two state governors coordinating fire service, emergency management, emergency medical services, public safety, and law enforcement for 12 years. She then served as the Associate Federal Emergency Management Agency (FEMA) Director for National Preparedness, Training, Higher Education, Exercises, and International Partnerships (presidential appointee, U.S. Senate confirmed unanimously). She was a private sector government contractor for 12 years, at the Texas firm, Electronic Data Systems (EDS) as senior emergency manager and homeland security advisor and SRA International’s director of emergency management services. She currently serves as a nonprofit leader on the Board of Advisors for DRONERESPONDERS International and for the Institute for Diversity and Inclusion in Emergency Management, and as graduate professor of Emergency Management at University of Nevada at Las Vegas for 16 years, İstanbul Technical University for 12 years, the MPA Programs Metropolitan College of New York for five years, and George Mason University. She has been a Certified Emergency Manager (CEM) for 25 years and a Featured IAEM CEM Mentor for five years, and Chair of the Training and Education Committee for six years, 2004-2010. She is also on the Advisory Board for Domestic Preparedness.