Adapting Existing Frameworks

Countermeasure dispensing is likely to be more successful if it capitalizes on and adapts processes that have already been successful in existing public- and private-sector networks, said panelist James Shortal, the director of business continuity at Cox Communications. One of the greatest logistical hurdles regarding countermeasure dispensing is its need for significant personnel resources regardless of whether staff are paid or volunteer. As previously discussed, the decision to utilize a medical or non-medical POD, as well as other layered strategies discussed below, could greatly impact that number of personnel required. One estimate highlighted during the workshop by Koonin, based on Baccam’s presentation, suggested that the Washington, DC, metropolitan area might require 60,000 to 100,000 volunteers to staff PODs. Local public health departments serving these large jurisdictions are extremely unlikely to possess that degree of staffing. Several speakers suggested that because it is infeasible to ensure the availability of such a large number of volunteers, public–private collaboration is ideal. “Think outside the POD” was the exhortation of speaker Koonin, capturing the importance of nontraditional measures to recruit sufficient staff and other steps to dispense countermeasures on a large scale. It was also mentioned that a corporate or large “big-box” retail entity could assist by providing its workforce, physical facility, and logistical support. These entities could be counted on regardless of federal planning grants and have a vested interest in preserving the community. The ability to integrate advance training and preparation in an identifiable group and entity was superior to just-in-time training of speculative volunteers.

Typical sites for large-scale community activities, such as stadiums and high schools, are other options for locating open PODs. To streamline logistics, Jeffrey Holmes, director of PRTM, spoke of adapting the U.S. Department of Defense’s logistics model called SCOR,⁶ which has been so successful that it is used outside the military, usually by private industry. These and other programs might be adapted to hasten the supply chain of medical countermeasures (through either push or pull mechanisms). Extra staffing for any of the functions performed at the POD could be obtained through partnerships with temporary staffing agencies, the panelist said. Another tactic involved the use of high-volume retailers.

Kevin Smith, national disaster services specialist for America’s Second Harvest, spoke of seeking help from local nonprofit organizations by using the distribution networks they have developed to meet the needs of special populations, including homeless and homebound people and nursing home residents. He spoke of tapping into “Second Harvest,” a network of more than 200 food banks throughout the United States. Second Harvest works with local agencies to serve, primarily through pull mechanisms, more than 50,000 pounds of food per month. The ability of nonprofit networks to dispense medical countermeasures critically depends on their current presence in any given community.

Using the nation’s vast network of home newspaper delivery contractors is yet another possible approach that could be employed as part of a layered communication and dispensing strategy, suggested John Murray, vice president of circulation marketing for the Newspaper Association of America. Murray pointed out that 1,250 daily newspapers serve approximately 40.5 million homes, businesses, and schools. Many independent contractors who deliver newspapers occasionally deliver product samples, ranging from shampoo boxes to cereal. In a survey of newspaper distributors, Murray said, 71 percent indicated they already deliver product samples or have the capacity to deliver them. Furthermore, newspaper publishers view themselves as deeply embedded in the community and carry an obligation to serve the public. The lead time needed to affix medical countermeasures to their delivery routes would be about 36 to 48 hours, Murray suggested. However, if given notice, Murray said, that time could be shortened.

A key point emphasized by several panelists was that recruiting and retaining extra labor for the dispensing effort hinges on ensuring that the personnel and their families are among the first to receive countermeasures or that they are provided MedKits to store at home in advance. One panelist’s experience showed that personnel are far more likely to show up in an emergency if they and their families are assured of being protected. Several events of national significance were cited illustrating this point, including the response to Hurricane Katrina.

This point reinforced the concept of a civil defense for the 21st century, which was highlighted by workshop co-chair Matthew Minson, senior medical advisor in the Office of the Assistant Secretary for Preparedness and Response, HHS. Minson mentioned that one consistent feature in the initial response to the hurricane was that a neighbor or citizen was immediately on hand to support other citizens before formal response organizations arrived. In addition, to further support personal preparedness states like Florida use state tax holidays to encourage purchasing of water and other necessities in advance of a hurricane. Given the imperatives of the CRI, Minson suggested this investment in the public is well advised.

Public–Private Partnerships

Forging novel partnerships between government agencies and the private sector is not just an option but a necessity, spurred by the magnitude of the U.S. population and the gravity of the threat, according to many speakers. Multiple types of public–private partnerships have already begun to flourish, and many more possibilities were raised at the workshop. The partnerships are wide ranging (Boxes 5 and 6), from negotiating complex logistical agreements to creating closed PODs. They typically provide advantages for each party. The structure of the partnerships is equally broad, covering open or closed PODs, and PODs using other push or pull mechanisms. This section highlights the diversity and flexibility of those partnerships, but begins with the fundamental principles underlying them. A summary of ideas that were presented by individuals during the meeting is also highlighted in Box 6.

BOX 5

Possible Activities Undertaken Through Public–Private Partnerships. Coordinating logistics, warehousing, and distribution of countermeasures. Setting up open points of dispensing (PODs) for dispensing countermeasures.

BOX 6

Ideas for Improving Current Planning Efforts. Create innovative frameworks, models, and partnerships for the public and private sectors to meet the massive challenge of dispensing countermeasures to affected populations (more...)

One principle is that a singular approach to dispensing is unrealistic. The most realistic approach is a layered one that combines several types of strategies, including short term and long term. One major example of a layered approach is the use of the U.S. Postal Service to provide the first several days’ worth of countermeasures in certain areas, followed by other methods (e.g., PODs) to dispense the remainder of the doses needed. Another example is prior placement of MedKits for in-home use at the beginning of a public health emergency, after which countermeasures could be dispensed at PODs or alternative sites, noted speakers Gregory Burel and Linda Neff of CDC. This concept was encouraged by a number of workshop participants, who noted that regardless of the additional methodology, enabling pre-positioning of MedKits would relieve pressure from the public health system during the initial 48 hours. As a point of equity, an analogy was drawn to hurricane response and allowing individuals to use their own cars to evacuate so that public transportation could serve less advantaged members of society. The idea is that those with fiscal means could procure a MedKit for themselves and their families, which would allow public health and the public–private dispensing mechanisms to focus greater attention and effort on getting antimicrobial prophylaxis to those who were not able to acquire a MedKit. The use of “pre-positioning,” however, is controversial and it was suggested by a workshop participant that perhaps prior placement of countermeasures should be restricted to public health personnel and other first responders, as opposed to the general public. Pre-positioning for first responders could mean that critical personnel and/or volunteers would be issued antibiotics after being identified and trained.

Another possibility is that local pharmacists, through public–private partnerships, could help to screen individuals who may need assistance, clinical evaluation, access to pharmaceutical records, and knowledge of drug–drug interactions, said presenter Mike Simko of Walgreens, a pharmaceutical chain with 6,000 U.S. pharmacies. Moreover, pharmacists have the added advantage of being able to perform immunizations in many states. Immunizations may be critical in a public health emergency and pharmacists may be able to offer their expertise to expand the workforce needed in an emergency. Similar points about the multiple clinical roles played by pharmacists were reiterated by Greg Sciarra of CVS Caremark.

Carter Mecher from the White House Homeland Security Council reinforced the idea that a combination of several partially effective actions, such as a layered strategy, would be needed to address the goal of rapidly dispensing countermeasures to a large population. Another principle is that the field is not starting from scratch. Many local governments, some described below, have already entered into partnerships with the private sector. Those partnerships are beginning to spring up in many localities and are tailored to meet precise local needs, according to speakers Teresa Bates of the Department of Public Health of Tarrant County, Texas, and Robert Mauskapf of the Virginia Department of Health. Bruce Baker, the SNS coordinator for the Maryland Department of Health and Mental Hygiene, described his experience working with a variety of private-sector partners including a major trucking company, Maryland public television, newspapers, and big-box retail stores. A final and interrelated principle is that no single approach will work for every community. Local governments say they are seeking a menu of options from which they can pick and choose to meet their specific needs, several speakers noted.

Any private establishment that can rapidly serve large numbers of customers represents a potential opportunity for a public–private partnership. Potential dispensing sites for open PODs could even include sites such as McDonald’s, Starbucks, and Wal-Mart, noted several panelists. Other sites might include restaurants, special pharmaceutical vending machines, retail stores, pharmacies, grocery stores, banks, automatic teller machines, and any other venue with drive-through facilities, Koonin said. She noted that McDonald’s serves thousands of customers a day at a single location. By entering into agreements with local governments, these organizations could be innovatively adapted to become pre-designated as open PODs. Agreements typically require the private party to provide security, staffing, and recordkeeping (on recipients of the countermeasure and/or the number and nature of any adverse events), among other elements. Developing model agreements (Memorandum of Agreement) for use by state and local governments and HHS would explore Public Readiness and Emergency Preparedness (PREP) Act provisions for liability and emergency protection allowances.

Lynne Kidder of the Business Executives for National Security highlighted the importance of establishing public–private partnerships at the local level, where personal relationships are more easily established and later maintained during an event. Jason Jackson, the Director of Emergency Management for Wal-Mart Stores, Inc., echoed the sentiment that experience has shown that public and private partners are able to work together extremely well during a disaster to solve problems, particularly if the groundwork has been laid in advance to establish a trusting relationship. Jack Herrmann, Project Director of Public Health Preparedness at the National Association of County and City Health Officials (NACCHO), also noted that it is important for local public health departments to reach out to and stay in touch with their current and potential business partners; frequent communication and collaboration can help to reduce the language and cultural differences between the public and private sectors. The CDC may also develop a template Memorandum of Agreement (MOA) to assist local governments and organizations in their efforts to create public–private partnerships, suggested Dulin.

Closed PODs

Closed PODs, which are not open to the public and instead focus on one particular group (such as a company’s employees and their families), may be an ideal means for large employers to partner with the public sector. The benefits to each partner are numerous. For the public partner, fewer people would need to be served at nearby open PODs. Pamela Blackwell, Director of the Center for Emergency Preparedness and Response for the Cobb and Douglas Boards of Health in Marietta, Georgia, estimated that the currently planned closed PODs in the metro Atlanta area might reduce the number of people who need access to open PODS in case of an event by 40 to 50 percent, allowing public health to focus on at-risk populations in places such as jails and nursing homes. There is even a multiplier effect, as the household members of the employee may also receive countermeasures at the closed POD. Panelist Shortal noted that, in the case of a 10,000-person corporate headquarters, the total served when their families are included might easily reach 50,000 people, or more. For the employer, a large benefit is that their employees feel more secure that they and their families are protected. Employee security may foster greater loyalty to the company, reduce turnover, and promote swifter return to commercial operations after the emergency, thereby restoring the company’s and possibly the local community’s economic viability (Lindner, 2006). However, employer concerns regarding potential liability from dispensing medications would need to be addressed, emphasized Shortal, Mugno, Jackson, Kidder, and other participants from the private sector.

Other benefits of closed PODs were articulated by speaker Karen Drenkard, chief nurse executive of Inova Health Systems in Virginia. Her health system has already become a closed POD by entering into a partnership with the government. That designation enabled her to purchase a cache of medications large enough to cover Inova Health Systems’ 17,000 employees. Ensuring coverage for hospital personnel (and their families) is imperative to ensure readiness of critical hospital staff and to minimize absenteeism from staff who may become ill or reluctant to come to work if they do not have countermeasures available to them early in the event.

Drenkard said Inova hospitals’ closed PODs have a dispensing capacity of 1,200 people an hour. For staffing at the closed PODs, her organization brought in nonclinical volunteers and trained them in groups of 10 to 20. To recruit more volunteers, Drenkard began a program that taps into nursing, pharmacy, and social work students. She and her staff also developed an “incident command system” with a clear chain of command. As part of a preregistration process, Drenkard set up a layered approach to distribute in advance a 3-day supply of countermeasures to homes of staff and family. The rest of the doses would be dispensed around the time of the emergency. However, provisions and guidance for the dispensing of countermeasures from closed POD had not been completely formulated.

Closed PODs have already proved to be appealing to large employers in Tarrant County in Texas. Panelist Teresa Bates reported that since 2006, she has been partnering with several local businesses and universities to create closed PODs. Her department requires the private-sector partner to have at least 600 employees to participate. As part of the signed agreements between the employer and the health department, the employer is required to provide medical staff and armed security during the event. Her department trains the employers’ POD staff as Medical Reserve Corps volunteers.

Preregistration and Prescreening of Individuals

For the broader problems of increasing efficiency and detecting adverse effects of countermeasures, regardless of whether PODs serve the public or private sector, Drenkard recommended a type of preregistration system akin to an E-ZPass,⁷ which is used on many highways to facilitate traffic flow by collecting tolls through advance registration. By gathering medical information in advance—with confidentiality protected—an individual could receive medical countermeasures more quickly, and be flagged ahead of time as at risk of suffering a drug–drug interaction or serious adverse effects (and thus receive a possible alternative drug). Medical recordkeeping is important not only to identify adverse effects in individuals, but it is also is an essential means to track whether a particular batch of a given countermeasure is contaminated. By tracing epidemiological patterns of adverse effects, in other words, epidemiologists will be able to determine whether an adverse event is an isolated case or whether it is tied to a contaminated lot of the countermeasure, for which a recall might be necessary.

PODs of any configuration can use information technology to dispense countermeasures in an efficient and swift manner. One potential way to achieve that was suggested by speaker Noah Glass, chief executive officer of GoMobo, Inc., a company that uses innovative mobile technologies to allow consumers to preorder food from restaurants online or via text message. Based on his experience, he outlined a similar system that could rely on cell phones and text messages to help individuals avoid long lines at PODs. Within less than 2 years, a system could be developed to pre-register individuals and families, acquire pertinent medical information, and provide detailed educational materials. At the time of an emergency, a text message or automated call to the owner of the cell phone would be used to assign a location and time at which the head of household (or other household member) should arrive at the POD. Once there the individual would identify the last four digits of a cell phone number or other code in order to obtain a prepackaged set of countermeasures in the amount necessary for the size of his or her household. However, as suggested by a participant, questions remain about the availability of cell phones during an event, so research may need to be conducted to determine how such a system could be developed to ensure it were operational during an event.

Despite the promise of preregistration and prescreening as a way to increase the efficiency of medical countermeasures dispensing in the case of an event, many important questions remain regarding the feasibility of this approach, including how to address privacy concerns as well as the technical challenges of creating, maintaining, and updating such a system.

Staffing Requirements

Public–private partnerships can be used to ensure coverage of additional essential functions at PODs or alternative sites of delivery, the foremost being extra staffing, communication, health education, and security. If insufficient staff are available, private partners that specialize in these areas or temporary agencies may be able to assist by recruiting extra staff as needed. For example, one option that was highlighted by speakers was the possibility of using the knowledge and expertise of pharmacists to help screen and triage persons arriving at PODs. Another example of using existing resources, noted speaker Henry, is to harness a large range of public employees currently serving the public, such as first responders, firefighters, and other types of public employees, including the National Guard. In the Washington, DC, metropolitan area, many jurisdictions already mandate service by public employees in case of an emergency. In addition, individuals serving in the Medical Reserve Corps and Community Emergency Response Teams may also be called upon to assist in these efforts. To describe the opportunities offered by temporary agencies, the workshop heard from Jonathan Means, senior vice president and general manager of central operations and businesses for Kelly Services. Temporary employment agencies have the expertise and systems to recruit staff within a short period of time and have the capacity to set up call centers, for example, to assist in the dissemination of important information.

However, although public–private partnerships offer a mechanism to strengthen capacity, many questions raised were left unanswered. For example, it was suggested that the POD model may require more than double the current public health staffing to implement, but is this an accurate estimate? Another question that remains unanswered is how repeated and/or multiple attacks would be handled, and how many staff and resources would be needed to do so.

Security

In many communities, the availability of public-sector security personnel to provide services during countermeasures dispensing is a rate-limiting step. Potential partnerships with private security firms specifically devoted to maintaining public safety and security to provide additional security resources may be a feasible solution to the shortage of public-sector security personnel. Christopher Hetherington, a crisis manager at Citigroup, noted that there are 1.8 million trained private security officers in the United States. The distribution of these private officers is widespread because they are employed at banks and other establishments throughout the country. Just as the Office of Homeland Security already foresees that these officers are a component of their plan to respond to catastrophic events, it is reasonable to anticipate partnerships for protecting the public at PODs and any other alternative sites. Issues regarding recruiting, credentialing, and training of these security personnel would need to be resolved, as would the matter of liability and compensation.

Communication Systems

Finally, communication with the public is a vital function long before, as well as during, a public health emergency. In the case of anthrax exposure, pressure on public and private PODs will be alleviated if exposed individuals know where to go to get medical countermeasures and how to seek medical attention if they are ill. All public health departments, for example, have pre-scripted messages that are ready to be sent out during a public health emergency; yet a multi-layered communication strategy is necessary to reach the greatest number of people. Developing excellent communication systems is an important goal for public–private partnerships, given the multiple avenues through which people now receive their news and education. One speaker observed that the more the public knows, the less likely they are to panic. Speaker Mauskapf spoke of his experience with maintaining strong working partnerships with the media serving his state, Virginia, including the National Association of Broadcasters and local and national newspapers. Mauskapf indicated that his organization is publishing information about and descriptions of anthrax in four languages. Speaker Neff also pointed out the challenge of communicating with and meeting the needs of non-English-speakers, and subsequently the necessity of developing appropriate communication strategies for non-English speakers. Other speakers pointed out the key role of the Internet for obtaining and updating information during a highly fluid crisis. Paul Freibert, a public health planner from the Kentucky Public Health Department, noted that one of his subcommittees routinely invites the television stations serving his state to be part of the planning process.

Footnotes

6

Supply Chain Operational Reference.

7

E-ZPass is an electronic toll collection system used throughout the northeast United States that allows participants in the program to preregister accounts so that tolls may be deducted from prepayments made by the users. A small, removable sign attached to the middle of the upper windshield allows participants to pass through tolls without stopping, which ultimately improves the flow rates at toll booths.