During and immediately after a major public health emergency – e.g., a bioterrorism attack, an influenza pandemic, a chemical or radiological event, or a natural disaster – lifesaving medical countermeasures are not always readily available to every person affected. At a time when the nation’s state and local governments are balancing public health preparedness activities with diminishing resources and decreased funding, there is a real need for creative, smarter, and more efficient ways to change this scenario and ensure that everyone has access to the medical countermeasures that are needed.
In light of recent budget cuts, it comes as no surprise that the staffing levels of state and local public health departments have dramatically decreased in the past several years. In fact, economic impact studies carried out by the National Association of County and City Health Officials (NACCHO) show that, since 2008, nearly 50,000 state and local public health jobs have been lost. An estimated 34,400 of those positions were in local health departments. NACCHO data further show that, between July 2010 and June 2011: (a) more than half of all local health departments affected reduced or eliminated at least one program; and (b) emergency preparedness ranked second on the list of programs experiencing significant reductions.
Moreover, in addition to the loss of staff, many jurisdictions also have been forced to implement staff furloughs and struggle in other ways with the inability to maintain staff for sustained planning and preparedness operations. When these realities are coupled with a declining tax base and an eroding public health infrastructure, it becomes obvious that a crisis is offstage just waiting to happen.
With the realities of an ever-changing budget environment and the need to continuously improve the U.S. response posture, a new era of public health planning for emergencies has surfaced where federal, state, and local planners are working together to develop and implement innovative ways to ensure that medical countermeasures efficiently reach those who need them in an emergency. At the forefront of these plans are partnership opportunities to build distribution and dispensing capabilities at the state and local levels – both to improve access to lifesaving medicines and to share responsibility across the community. This approach requires that non-traditional public health partners – e.g., private businesses, academia, community agencies, faith-based organizations, healthcare facilities, and governmental entities, including military installations – participate during an emergency to ensure that lifesaving medicines and other material resources are provided to more people in a shorter amount of time.
Federal staff at the Centers for Disease Control and Prevention’s (CDC) Strategic National Stockpile – the largest government stockpile of medical countermeasures that can be deployed in a public health emergency – have embarked on a mission to help state and local jurisdictions forge these outside partnerships in order to not only improve countermeasure distribution and dispensing capabilities but also to increase access to critical medications at the time of a public health emergency.
How States Receive Medical Countermeasures in an Emergency The Strategic National Stockpile – a repository of antibiotics, chemical antidotes, antitoxins, vaccines, antiviral drugs, and other lifesaving medical material – was created by Congress in 1999 as a federal asset designed to store medical countermeasure resources and to remain poised to deliver them to the site of a national emergency, if needed. At the time of an emergency, a state (or U.S. territory or freely associated state) will determine if there is a need for federally stockpiled assets and would then formally request federal assistance.
Following a request to the U.S. Department of Health and Human Services, discussions between state and federal organizations are initiated and a decision is then made at the federal level on whether to distribute the countermeasure resources that have been requested. After federal, state, and local health officials determine what is needed, the materials provided are delivered to a pre-determined site; state and local authorities then become responsible for further distribution. It is at this point that the responsibility for distribution, dispensing, storage, and maintenance of the countermeasure resources is assumed by the state and, ultimately, local jurisdictions.
Medical countermeasures then must be dispensed in a clinically relevant timeframe, as dictated by the specific emergency. For instance, current clinical guidance mandates that, in order to be protected, people exposed to anthrax must receive countermeasures within 48 hours of exposure. In this scenario, public health personnel at the federal, state, and local levels must request and deploy products from the Strategic National Stockpile, deliver them to the state and distribute them to local jurisdictions, set up various points of dispensing (PODs), communicate essential information to the public about where to receive countermeasures, and dispense pills to those who have been exposed – all in a maximum of 48 hours. In this type of rapid emergency response, mass-dispensing methods will be used, as prescriptions are not needed to dispense medications to those who are affected.
Nontraditional Partners Assist in Mass-Dispensing Efforts In a public health emergency that requires countermeasures from the Strategic National Stockpile, state and local public health are often working against the clock to quickly distribute and dispense medical countermeasures to the affected population. Nontraditional partners in the dispensing process can make a major impact in such emergencies by supplementing local efforts to get lifesaving countermeasures to those in need. With this kind of support, local public health personnel can then focus on other essential activities like surveillance, epidemiology, public information and communications, and reaching vulnerable populations.
One successful approach in improving response capabilities is through a partnership where public and private organizations assist with dispensing medications to their own pre-identified populations through dispensing sites called “closed” PODs. Medications are provided to closed POD partners at no cost, and public health personnel collaborate with and assist the partners in planning, training, and exercising. For many partners, medical countermeasures are offered to employees and their families not only as a benefit provided by the organization but also as a way to redirect these specific populations away from the public PODs.
Here it is worth noting that, in a recent pilot project focusing on the hospitality industry, public health planners tested the concept of using a national business to operate closed PODs in multiple locations across the country for an event requiring the mass dispensing of antibiotics. In addition to verifying that large national businesses are both interested in and capable of conducting dispensing operations in support of a public health emergency, the pilot project showed that the operation of closed PODs ultimately allows nontraditional partners an improved continuity of operations by helping their staff to either: (a) return to normal duties within the organization more quickly; or (b) continue to assist public health officials by volunteering.
Federal staff have now expanded their own role in fostering such partnerships between nontraditional partners and state and local public health planners by devoting full-time personnel to recruiting, training, and pairing public health jurisdictions with these types of partners.
Improving Access to Antiviral Drugs Through Controlled Dispensing Whereas an anthrax response may and frequently does require mass antibiotic dispensing to large numbers of potentially exposed people, there are other scenarios – an influenza pandemic, for example – that could require prescription-based countermeasure dispensing over an extended period of time for the duration of an outbreak. Largely for that reason, CDC has initiated another innovative project to explore the use of private partnerships for alternative methods of distributing and dispensing antiviral drugs during a pandemic.
Making the antiviral drugs held in the Strategic National Stockpile available through pharmacies with a prescription – a practice known as controlled dispensing – is a logical solution for an influenza response that requires the distribution and dispensing of prescription drugs over the course of several months. However, this proposed model is not operationally useful, or appropriate, for responses that require rapid, short-term deliveries to large numbers of people, as would be the case to cope with a more complicated event such as a biological attack – with anthrax, for example.
Using the pharmaceutical supply chain – pharmaceutical distributors and pharmacies – to distribute and dispense drugs during an emergency can help improve access to antiviral drugs during a pandemic and relieve some of the local dispensing burden during an extended event. In order to assess the feasibility of using the pharmaceutical supply chain in an influenza event, CDC partnered with a large chain pharmacy in an urban setting, and with a small retail pharmacy in a less populated community, to “exercise” the scenario and determine possible pharmacy dispensing throughput during an emergency. That exercise produced several favorable results involving the use of pharmacies for the controlled dispensing of medical countermeasures. Other studies also have been carried out exploring related topics and issues such as feasibility, acceptability, costs, and overall impact of using pharmaceutical distributors and pharmacies as partners in distributing and dispensing medicines and drugs during an influenza pandemic.
Nontraditional Partnerships Vital to Securing Nation’s Health Following the 11 September 2001 terrorist attacks, a greater focus has been placed on medical countermeasure planning and response. In the 11 years that have passed since the attacks, planning has continued to evolve to incorporate lessons learned from many other emergency responses, including those carried out following Hurricane Katrina and the 2009 H1N1 pandemic. Collectively, those lessons have persuaded public health personnel to realize the value of leveraging everyday systems – and nontraditional partners – to advance and enhance distribution and dispensing plans.
As long as state and local budgets continue to decrease, while staffing levels remain threatened, the use of nontraditional partnerships to support distribution and dispensing efforts will become even more important in sustaining the response capabilities necessary for securing the nation’s health during and in the wake of major disasters. Fortunately, the initial partnerships already formed show that all involved can benefit by reducing the strain on diminished public resources – while also facilitating the continuity of operations for nontraditional partners that, in turn, provide their specific populations with the lifesaving use of appropriate medical countermeasures.
Nonetheless, if public health is to continue to promote the certainty that medical countermeasures will be available to protect lives in future times of emergency, it is vitally necessary to develop and use additional innovative and creative ways to further improve emergency preparedness and response capabilities. By sharing the responsibility with willing and capable partners, public health personnel will be able to save more lives by effectively and efficiently getting medical countermeasures to those who need them the most during a real-life emergency.
For additional information on: NACCHO’s economic impact studies, visit http://www.naccho.org/press/releases/12-20-2011.cfm
________________________ Greg Burel is the Director of the Strategic National Stockpile managed by the Centers for Disease Control and Prevention. As head of the nation’s largest stockpile of medicines and supplies available for emergency use, he is a leading expert on medical countermeasure distribution and dispensing throughout the United States. With more than 30 years of civil service, he has risen through the ranks of the federal government, beginning his career at the Internal Revenue Service and serving in leadership roles in both the General Services Administration and the Federal Emergency Management Agency. In 2006, he assumed the helm of Strategic National Stockpile operations. In addition to his professional interests at CDC, he is past flotilla commander of the United States Coast Guard Auxiliary's Flotilla 24 headquartered in Lake Lanier, Georgia.
Significant contributions to this article were made by Stephanie M. Bialek, Centers for Disease Control and Prevention.
Stephanie M. Bialek, is lead health communications specialist for the Division of Strategic National Stockpile, Centers for Disease Control and Prevention. With more than 10 years of public relations and communications experience in government, academia, and health care, she joined the federal government in 2010 to provide communications expertise and strategy along with writing and editing services, content development, and electronic media solutions. She holds both a bachelor’s and master’s degree in journalism and mass communications from the University of Georgia.