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Medical Countermeasures Following a Biological Attack

January 5, 2010

On December 30, President Obama signed an extremely important Executive Order regarding the delivery of medical countermeasures in the aftermath of a biological attack. In our parlance, that means SNS. (All of my CRI friends’ ears just perked up, did you see that?)

I got a big kick out of this EO because it deals very specifically with something that I’m a huge fan of: using the Postal Service, or USPS, to deliver countermeasures door-to-door. The idea behind the program is that in the event of a biological attack that required rapid deployment of medical countermeasures (think aerosolized anthrax requiring the rapid distribution of ciprofloxacin and doxycycline) public health officials should look for support from the people who manage to distribute large volumes of possibly sensitive material to all citizens and residents every day. In short, why try to reinvent the wheel when there are experts ready, willing and available to help.

The existing accepted model of countermeasure distribution right now is the POD, or point of dispensing, model. This is where the public health authority sets up a location to give out countermeasures to everyone that shows up with the goal of reducing face-to-face contact with healthcare professionals in order to speed dispensation. The morning that the POD is set up, the local news says which school or large government controlled building to show up to, and everyone goes and gets in line. And waits.

Everyone who does this type of planning, or really any type of event planning (be it large concerts or security details or whatever), will see the myriad problems with that plan right away. If that crowd gets out of hand, you’ve got either thousands of victims, or rioters.  What do you do about bathrooms? What do you do about inclement weather? What do you do about rumors in the line?

Then there’s the epidemiological problem of this approach. How can you ensure that the people in front of the line are those most likely to have been exposed? It’s not at all inconceivable to think that someone who was exposed could literally die from their anthrax exposure while waiting in line for the countermeasure.

I’ve heard of some plans to alleviate these problems, like having drive-through PODs, or having huge PODs that can service hundreds of people at a time, but all of them still fail at addressing the huge line and prioritization problems.

A few years back, Philadelphia was the second city to test a plan to use USPS mail carriers to deliver countermeasures door-to-door. (Seattle was the first, Boston was the third and Minneapolis the most recent.) I talked about the Philly one at the time here. By all reports, each was a huge success.

The criticisms of using the postal service are many, but I think, when compared to a cold start POD setup, are much more easily dealt with. The first criticism is the security of the mail carriers. In each of the tests, each mail carrier was assigned a police officer escort. In a city like Philadelphia, I can’t imagine there would be enough police officers to do that. Some sort of general quarantine or curfew would have to be imposed to lessen the risk to the mail carriers. Another criticism is that the effort couldn’t be maintained. A full course of anthrax countermeasures is taken over sixty days. Twice a day. 120 pills per person per household?  And assuming you just dropped off a bit on each go-around while it was delivered via SNS, there’s no way to know if people moved from house to house and would’ve missed the rest of their course. The best response to this that I’ve heard is that the postal strategy is just one of a number of ways that public health authorities would be distributing meds. Consider this scenario, for example.

A covert anthrax attack occurs. Time goes by and people begin showing up all over the city with symptoms of inhalational anthrax exposure. As a public health official, you have a need to distribute antibiotics ASAP, seemingly everywhere. Using the planning talked about in the linked EO, you bring in the USPS, install a temporary curfew and deliver a bottle of doxycycline to each household in the city in 14 hours (remember, they deliver to every household every day in less time than that now).

While this is happening, two other efforts are taking place. One is that the public health authority is setting up PODs; drive-through, mega-PODs, neighborhood PODs, whatever. At the same time, local and state epidemiologists are pinpointing the location of the release and identifying those exposed. Say all of those exposed were at a professional football game. You now know your target population. Those living around the stadium and everyone who attended the game.

So, you set up PODs that are only open to those exposed. That way, instead of having to staff and locate 100 or more PODs, and instead of having 85-year-old grannies who hate football and live on the other side of city stand in line in twenty-degree weather for 32 hours, you’ve targeted your response. You’ve freed up police forces after that initial curfew order (think: it’s a lot easier to secure two or three strategically located PODs than 100 or more across the city), you’ve made your staffing and planning efforts actually feasible and can give the required meds (remember the sixty-day course) to those most likely to need it.

Coupled with a robust public information effort, this might actually work. Well, at least a lot better than what we would have had to put that poor old granny through.

Now, with this EO in effect, real planning, with the force of the White House, can commence. Maybe this isn’t the plan for everywhere, but at least the groundwork will be laid in those places that it will work.

And according to Section 2 of the EO, it should happen quickly:

(b) The Secretaries of Health and Human Services and Homeland Security, in coordination with the U.S. Postal Service, within 180 days of the date of this order, shall establish a national U.S. Postal Service medical countermeasures dispensing model for U.S. cities to respond to a large-scale biological attack, with anthrax as the primary threat consideration.

(c) In support of the national U.S. Postal Service model, the Secretaries of Homeland Security, Health and Human Services, and Defense, and the Attorney General, in coordination with the U.S. Postal Service, and in consultation with State and local public health, emergency management, and law enforcement officials, within 180 days of the date of this order, shall develop an accompanying plan for supplementing local law enforcement personnel, as necessary and appropriate, with local Federal law enforcement, as well as other appropriate personnel, to escort U.S. Postal workers delivering medical countermeasures.

Very cool stuff, and a big leap forward in CRI planning.

Hat tip to one of my old favorites, On the Homefront: the blog of the Homeland Security Digital Library at the Naval Postgraduate School Center for Homeland Defense and Security.

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One Comment leave one →
  1. January 5, 2010 2:36 pm

    We looked at this comparison (USPS vs POD) when I was at a LHD and all of the jurisdictions came down on the side of the POD. Mainly because of the manpower issue – nobody had enough police to meet the USPS requirements for security, which were on the order of 2-5 officers per truck. They were looking at using the larger delivery van type vehicles (not the single-seat Jeeps).

    My biggest issue with this EO is the same one I have with CRI in general – while everything else in emergency preparedness is attempting to go all hazards CRI is a giant step backwards, in the direction of single incident planning. None of the CRI plans are applicable to any other biological, because: 1) anthrax is not contagious and 2) anthrax is easy to treat if recognized early. That second point is the biggest reason CRI planning falls apart for any other biological, because only with anthrax do you have the possibility of being able to give out prophylactic treatment meds (in this case, courses of antibiotics) without needing medical personnel to evaluate every single potential patient and determine if they really need them. Even most pandemic planning (specifically the HHS guidance) held antivirals for treatment only with prescription, which CRI does not do.

    Whether or not the USPS delivery model is better than PODs isn’t my primary concern about this. My primary concern is the massive amount of money that is currently being literally flushed down the toilets in all of the CRI communities because all of the doses of anthrax antibiotics they had to buy have expired. Let’s take a little time and rethink the approach before flushing millions more.

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