Mass Dispensing Research Articles

Walking distance for vulnerable populations to public health emergency response points of dispensing in New York City.

During certain public health emergencies, points of dispensing (PODs) may be used to rapidly distribute medical countermeasures such as antibiotics to the general public to prevent disease. Jurisdictions across the country have identified sites for PODs in preparation for such an emergency; in New York City (NYC), the sites are identified based largely on population density. Vulnerable populations, defined for this analysis as persons with income below the federal poverty level, persons with less than a high school diploma, foreign-born persons, persons of color, persons aged ≥65 years, physically disabled persons, and unemployed persons, often experience a wide range of health inequities. In NYC, these populations are often concentrated in certain geographic areas and rely heavily on public transportation. Because public transportation will almost certainly be affected during large-scale public health emergencies that would require the rapid mass dispensing of medical countermeasures, we evaluated walking distances to PODs. We used an ordinary least squares (OLS) model and a geographically weighted regression (GWR) model to determine if certain characteristics that increase health inequities in the population are associated with longer distances to the nearest POD relative to the general NYC population. Our OLS model identified shorter walking distances to PODs in neighborhoods with a higher percentage of persons with income below the federal poverty level, higher percentage of foreign-born persons, or higher percentage of persons of color, and identified longer walking distances to PODs in neighborhoods with a higher percentage of persons with less than a high school diploma. Our GWR model confirmed the findings from the OLS model and further illustrated these patterns by certain neighborhoods. Our analysis shows that currently identified locations for PODs in NYC are generally serving vulnerable populations equitably-particularly those defined by race or income status-at least in terms of walking distance.

Assessment of Emergency Preparedness Modules in Introductory Pharmacy Practice Experiences

Objective. To determine the impact of emergency preparedness simulations in mass triage and mass dispensing on student pharmacist performance and perceived competency when assuming pharmacist roles in disaster situations. Design. Second-year student pharmacists (144) completed two 3-hour simulations focusing on mass triage and mass dispensing. The mass triage simulation consisted of virtual and live victims to be triaged and assigned a transport order. In the mass dispensing simulation, students assumed patient and pharmacist roles in a point-of-dispensing exercise for influenza. Assessment. For the mass triage simulation, students were challenged most by determining which patients could wait for emergency care but did well assessing those who required immediate or minimal care (83% and 64% correct, respectively). During the mass dispensing simulation, students performed screening and dispensing functions with accuracy rates of 88% and 90%, respectively. Conclusion. Student pharmacists performed well in screening and dispensing functions, but struggled with mass casualty triage during emergency preparedness simulations.

Are US jurisdictions prepared to dispense medical countermeasures through open points of dispensing? Findings from a national study.

Communities will rely on open points of dispensing (PODs) for mass dispensing of medical countermeasures following a bioterrorism attack or a pandemic. US Cities Readiness Initiative (CRI) open POD preparedness is assessed using the Technical Assistance Review (TAR) but focuses on oral prophylaxis dispensing; mass vaccination readiness is not well measured. Non-CRI preparedness had not been studied. In 2013 an online questionnaire was sent to all 456 CRIs and a random sample of 500 non-CRIs to measure open POD preparedness and exercise participation. Hierarchical linear regression was used to describe factors associated with higher POD preparedness and exercise participation scores. In total, 257 subjects participated, for a 41% response rate. Almost all open PODs have existing written plans and/or a layout for each site (93.4%, n=240, and 87.0%, n=220). Only half (46.7%, n=120) have an alternative dispensing modality in place, and even fewer (42.6%, n=104) report having adequate staffing. Determinants of open POD preparedness were perceived preparedness, participation in more POD exercises, and more closed POD coverage. Most jurisdictions conducted a full-scale exercise and a staff notification drill (83.7%, n=215 for both). Fewer than half (40.5%, n=104) have conducted a vaccination clinic exercise. Determinants of increased POD exercises were perceived preparedness, years of work experience, community type (nontribal), and larger population. Because successful open POD deployment is critical, jurisdictions need to plan for mass vaccination, use of alternative dispensing modalities, and recruitment strategies to increase POD staffing.

The 49th hour: analysis of a follow-up medication and vaccine dispensing field test.

Anthrax response plans, exercises, and assessments over the past decade have focused almost exclusively on the first 48 hours of the public health response following a jurisdiction-wide exposure and provision of an initial 10-day supply of antibiotics from the Strategic National Stockpile (SNS). But mass dispensing of the subsequent 50-day course of antibiotics and administration of the 3-dose vaccine series have received considerably less attention, although these follow-up activities may prove even more complex. In 2014, the Philadelphia Department of Public Health (PDPH) made its first foray into this next frontier of mass prophylaxis planning by: (1) researching patient safety and adherence considerations relevant to the antibiotics in the SNS; (2) designing a model for a second-visit antibiotic and vaccine point of dispensing (POD), including development of an enhanced screening protocol that assumes a higher level of medical responsibility; and (3) field testing this model during a real seasonal influenza vaccination clinic to assess throughput and accuracy and to evaluate the resources needed to operationalize this model. While the observations and data presented here provide some framework for local long-term mass prophylaxis planning efforts, many areas remain undefined, including the distribution of responsibilities among the public health and healthcare communities to ensure patient safety. In addition to presenting findings, the larger intent of this article is to initiate a dialogue with other stakeholders at the local, state, and federal levels to advance long-term mass prophylaxis planning.

Infection prevention and mass vaccination training for U.S. point of dispensing staff and volunteers: A national study

Points of dispensing (PODs) are deployed for medical countermeasure mass dispensing. However, infection prevention and vaccine administration pre-event training offered and just-in-time (JIT) education planned for POD workers have not been assessed. Disaster planners were sent an online questionnaire in 2013. McNemar tests compared training offered to staff versus volunteers and pre-event training versus JIT training. In total, 301 disaster planners participated. The most frequent pre-event training included hand hygiene (59.1% and 28.0%) and personal protective equipment (PPE) selection (52.1% and 24.1%) for staff and volunteers, respectively. Few provided pre-event training on the cold chain technique (14.8% and 5.1%) or smallpox vaccine administration (4.7% and 2.3%) for staff or volunteers. For all topics except smallpox vaccine administration, more staff than volunteers received pre-event training (P<.01). The most frequent planned JIT training includes hand hygiene (79.8% and 73.5%) and PPE selection (79.4% and 70.0%) to staff and volunteers. For all topics, more JIT education is planned for staff than volunteers (P<.001). More JIT training is planned than has been given pre-event for all topics (P<.001). More pre-event training is needed on infection prevention and vaccine administration to ensure safe and successful POD deployment.

A national study examining closed points of dispensing (PODs): existence, preparedness, exercise participation, and training provided.

The Centers for Disease Control and Prevention recommends using open points of dispensing (PODs) and alternative modalities, such as closed PODs, for mass dispensing of medical countermeasures. However, closed POD existence has not been assessed. In 2013 we sent an online questionnaire to US Cities Readiness Initiative (CRI) and non-CRI public health disaster planners. Chi-square tests were used to determine differences between CRIs and non-CRIs when comparing having at least 1 closed POD, and to compare having a closed POD and perceived mass dispensing preparedness. A total of 301 disaster planners participated. Almost all (89.3%, n=218) jurisdictions have considered establishing a closed POD, and three-quarters (74.2%, n=181) currently have at least one. CRIs were more likely than non-CRIs to have a closed POD (85.0% vs 58.5%, X(2)=21.3, p<.001). Those with 1 or more closed PODs were more likely to believe their jurisdiction could distribute medical countermeasures within 48 hours compared to those without a closed POD (78.5% vs 21.5%; X(2)=10.8, p=.001). Half had a written plan and/or written standing orders (59.1% and 52.5%, respectively). Almost half (42%, n=72) have done no preevent training for POD staff in the past 2 years; almost 20% (18%, n=32) do not plan to offer any just-in-time training. Nearly 40% (n=70) have conducted no exercises in the past year. Closed PODs contribute to community preparedness; their establishment should be followed by development of written plans, worker training, and exercises.

Advancing Public Health and Medical Preparedness with Operations Research

Planning for a catastrophe involving a disease outbreak with the potential for mass casualties is a significant challenge for emergency managers. Public health experts at the US Centers for Disease Control and Prevention (CDC) teamed with operations researchers to address important aspects of mass dispensing: medical supply distribution, locations of dispensing facilities, optimal facility staffing and resource allocation, routing of the population, and dispensing methods. Simulation-optimization technology was integrated into a decision support and data management suite, RealOpt©, for tactical and strategic operational planning. RealOpt has enabled the CDC to provide modern tools that support dynamic planning for emergencies and that establish a knowledge data bank to provide feedback about the deployment of various techniques. The RealOpt suite now has a US user base of over 6,500 public health and emergency directors covering all states, plus many international users. RealOpt has been applied in hundreds of drills and dispensing events, including anthrax preparedness, and for seasonal flu and H1N1 vaccination events.

The Role of the Drug Information Center in Disaster and Emergency Preparedness

Purpose The objective of this article is to describe an innovative practice model that involves the drug information centers and drug information specialists in the Alabama Department of Public Health's (ADPH) response procedure to a terrorism event or natural disaster that requires mass dispensing of a pharmaceutical product. Summary A descriptive account is provided of a strategic partnership between the ADPH and the drug information centers located in the state of Alabama. These sites have been contracted to supply information services to patients during an event where a disaster response is required and adequate patient information regarding the disease state and drug product may be lacking. These sites are utilized on a rotating basis, with the ADPH obligated to provide infrastructure and access to the drug information specialists providing information and counseling over the telephone to patients. These services can be funded through federal and state agencies to support the equipment and personnel needed during a response. Conclusion Drug information centers in Alabama play a key role in the plan for providing reliable and unbiased information to patients during a disaster event where an ADPH response is needed.

Facility location and multi-modality mass dispensing strategies and emergency response for biodefence and infectious disease outbreaks

Mass dispensing for medical prophylaxis and treatment of the general population requires rapid establishment of a network of dispensing sites and health facilities that are flexible, scalable and sustainable. In this article, we describe a systems approach to analyse mass dispensing of countermeasures, and present a set of powerful modelling and computational tools to assist in strategic and operational planning. Facility location models are used to determine the number of dispensing sites required. Our models account for variable population densities, the maximum distance individuals should have to travel, the types of private and public facilities available and the availability of critical staff to man the point-of-dispensing facilities (PODs). Large-scale simulation is employed to model the stochastic service and dynamic flow behaviour within PODs; and optimisation is interwoven to determine appropriate staffing levels for efficient operations logistics. A cost?effective mass dispensing network for anthrax prophylaxis involving a metropolitan area with over 5 million people is presented. The study reveals that: (1) the sharing of labour resources across counties and districts is important; (2) the most cost?effective dispensing plan across a region involves a multi-modality strategy, consisting of a combination of drive-through, walk-through and closed PODs, each operating at a throughput rate depending on the surrounding population density, facility type and labour availability; (3) the optimal combination of POD modalities changes according to various facility capacity restrictions, as well as the availability of critical public health personnel; (4) an increase in the number of PODs in operation does not necessarily increase the total number of core public health personnel needed; (5) optimal staffing is non-linear with respect to throughput; thus, the optimal staffing and throughput cannot simply be estimated using an average estimate; (6) there exists an 'optimal' capacity for each POD location, depending on the population, that provides the most effective staffing needs. The study also reveals that such computationally sophisticated decision support tools are invaluable to emergency managers. The tools provide flexibility to quickly analyse design strategies and decisions, and can generate a feasible regional dispensing plan based on the best estimates and analysis available, and then allow for reconfiguration of various PODs as the event unfolds. The type of disaster being confronted (e.g. biological attack, infectious disease outbreak or natural disaster) also dictates different design considerations with respect to the dispensing clinic, facility locations, dispensing and backup strategies, and level of security protection.

Montgomery County’s Public Health Service Uses Operations Research to Plan Emergency Mass Dispensing and Vaccination Clinics

To curb outbreaks of contagious diseases, county health departments must set up and operate clinics to dispense medications and vaccines. Carefully planning these clinics in advance of such an event is difficult and important. We developed and implemented operations research models to improve clinic planning for the Montgomery County (Maryland) Public Health Services. They include discrete-event simulation models and capacity-planning and queueing-system models. We validated these models using data that we collected during full-scale simulations of disease outbreaks. We also developed guidelines for the physical design of clinics based on general queueing principles and our own experiences.

Business and public health collaboration for emergency preparedness in Georgia: a case study

BackgroundGovernments may be overwhelmed by a large-scale public health emergency, such as a massive bioterrorist attack or natural disaster, requiring collaboration with businesses and other community partners to respond effectively. In Georgia, public health officials and members of the Business Executives for National Security have successfully collaborated to develop and test procedures for dispensing medications from the Strategic National Stockpile. Lessons learned from this collaboration should be useful to other public health and business leaders interested in developing similar partnerships.MethodsThe authors conducted a case study based on interviews with 26 government, business, and academic participants in this collaboration.ResultsThe partnership is based on shared objectives to protect public health and assure community cohesion in the wake of a large-scale disaster, on the recognition that acting alone neither public health agencies nor businesses are likely to manage such a response successfully, and on the realization that business and community continuity are intertwined. The partnership has required participants to acknowledge and address multiple challenges, including differences in business and government cultures and operational constraints, such as concerns about the confidentiality of shared information, liability, and the limits of volunteerism. The partnership has been facilitated by a business model based on defining shared objectives, identifying mutual needs and vulnerabilities, developing carefully-defined projects, and evaluating proposed project methods through exercise testing. Through collaborative engagement in progressively more complex projects, increasing trust and understanding have enabled the partners to make significant progress in addressing these challenges.ConclusionAs a result of this partnership, essential relationships have been established, substantial private resources and capabilities have been engaged in government preparedness programs, and a model for collaborative, emergency mass dispensing of pharmaceuticals has been developed, tested, and slated for expansion. The lessons learned from this collaboration in Georgia should be considered by other government and business leaders seeking to develop similar partnerships.

Decision support system for mass dispensing of medications for infectious disease outbreaks and bioterrorist attacks

A simulation and decision support system, RealOpt©, for planning large-scale emergency dispensing clinics to respond to biological threats and infectious disease outbreaks is described. The system allows public health administrators to investigate clinic design and staffing scenarios quickly. RealOpt© incorporates efficient optimization technology seamlessly interfaced with a simulation module. The system's correctness and computational advantage are validated via comparisons against simulation runs of the same model developed on a commercial system. Simulation studies to explore facility layout and staffing scenarios for smallpox vaccination and for an actual anthrax-treatment dispensing exercise and post event analysis are presented. The system produces results consistent with the model built on the commercial system, but requires only a fraction of the computational time. Each smallpox scenario runs within 1 CPU minute on RealOpt©, versus run times of over 5–10 h on the commercial system. The system's fast computational time enables its use in large-scale studies, in particular an anthrax response planning exercise involving a county with 864,000 households. The computational effort required for this exercise was roughly 30 min for all scenarios considered, demonstrating that RealOpt© offers a very promising avenue for pursuing a comprehensive investigation involving a more diverse set of scenarios, and justifying work towards development of a robust system that can be widely deployed for use by state, local, and tribal health practitioners. Using our staff allocation and assignments for the Anthrax field exercise, DeKalb county achieved the highest throughput among all counties that simultaneously conducted the same scale of Anthrax exercise at various locations, with labor usage at or below the other counties. Indeed, DeKalb exceeded the targeted number of households, and it processed 50% more individuals compared to the second place county. None of the other counties achieved the targeted number of households. The external evaluators commented that DeKalb produced the most efficient floor plan (with no path crossing), the most cost-effective dispensing (lowest labor/throughput value), and the smoothest operations (shortest average wait time, average queue length, equalized utilization rate). The study proves that even without historical data, using our system one can plan ahead and be able to wisely estimate the required labor resources. The exercise also revealed many areas that need attention during the operations planning and design of dispensing centers. The type of disaster being confronted (e.g., biological attack, infectious disease outbreak, or a natural disaster) also dictates different design considerations with respect to the dispensing clinic, facility locations, dispensing and backup strategies, and level of security protection. Depending on the situation, backup plans will be different, and the level of security and military personnel, as well as the number of healthcare workers required, will vary. In summary, the study shows that a real-time decision support system is viable through careful design of a stand-alone simulator coupled with powerful tailor-designed optimization solvers. The flexibility of performing empirical tests quickly means the system is amenable for use in training and preparation, and for strategic planning before and during an emergency situation. The system facilitates analysis of “what-if'' scenarios, and serves as an invaluable tool for operational planning and dynamic on-the-fly reconfigurations of large-scale emergency dispensing clinics. It also allows for “virtual field exercises” to be performed on the decision support system, offering insight into operations flow and bottlenecks when mass dispensing is required for a region with a large population. The system, designed in modular form with a flexible implementation, enables future expansion and modification regarding emergency center design with respect to treatment for different biological threats or disease outbreaks. Working with emergency response departments, further fine-tuning and development of the system will be made to address different biological attacks and infectious disease outbreaks, and to ensure its practicality and usability.

Pandemic Influenza Preparedness: Adaptive Responses to an Evolving Challenge

In the United States, preparation for a potential influenza pandemic is receiving heightened media coverage and scrutiny. Scientific attention is focused on the potential for the current Southeastern Asian avian flu virus, influenza A (H5N1), to become a pandemic threat through genetic mutation and viral reassortment. It is imperative that we act now, as we face an evolving and advancing disease state with insufficient national preparation. Existing preparedness plans address laboratory and disease surveillance, community containment and border protection, and mass dispensing and vaccination strategies. However, little attention has been directed to identifying and managing psychological and social factors likely to influence human behavior during a pandemic. All of our health and medical strategies require people to behave in prescribed ways to avoid exposure, prevent infection, or halt disease transmission. This article provides timely expert panel recommendations for pandemic influenza response and recovery by addressing human behavior and adaptation.