1. SNS Planning and Capabilities Update
Greg Burel
Director, Division of Strategic National Stockpile
Office of Public Health Preparedness and Response, CDC
2011 Public Health Preparedness Conference
June 29th, 2011

2. Agenda Mission Technical Assistance Executive Order 13527
PAHPA Reauthorization
Novel Distribution and Dispensing Models
Challenges

3. Strategic National Stockpile Mission
Deliver critical medical assets
to the site of a national emergency
Stockpiling the assets and delivering them is important work
That work is wasted if the capabilities and resources don’t exist at the state and local level to utilize the assets
Collaboration is key to making the SNS a continuing resource to the nation

4. Technical Assistance

5. DSNS Modeling Support Distribution TourSolver
Optimized Distribution Routing software
396 registered users (as of 4/10/2009)
CERA
Modeled RSS capabilities in 36 cities
Two year contract ended 12/2008
Dispensing
RealOpt
Optimization tool for designing PODs and treatment clinic planning and operations
Modeling Forum (snsmodeling.org)
Purpose of promoting the exchange of ideas, models and simulations designed to improve emergency response efforts and public health
74 registered users
TourSolver for distribution:
TourSolver is a software that enables planners to quickly generate optimized distribution routes for their entire fleet of vehicles, It can be used to help deliver supplies from receive, store and stage (RSS) facilities or regional distribution nodes, to points of dispensing (PODs) and alternate care facilities. Users may customize parameters to reflect local conditions, run multiple scenarios, and ask “what if” questions that will simulate real world events. Planners, using multiple or as few constraints as desired, can then quickly assess the impact of these conditions on the overall distribution operation.
RealOpt for dispensing:
RealOpt is a modeling and optimization software tool for designing PODs and treatment clinic planning and operations. This software was developed by the Center for Operations Research in Medicine and HealthCare, School of Industrial and Systems Engineering, Georgia Institute of Technology.
RealOpt uses time study data collected from POD and alternate care facility exercises to allow planners to analyze POD/clinic designs. Using the models created with RealOpt will help POD and clinic planners identify and eliminate bottlenecks, maximize throughput and minimize the average time patients spend in the POD or clinic. This software provides project areas with the ability to:
Design customized and efficient POD floor plans using an automatic graph-drawing tool
Determine optimal labor resources and most efficient staff allocation
Equalize utilization across POD/clinic stations
Assess current resources and determine minimum needs for the regional population
Conduct large-scale virtual drills and performance analyses
In addition to the software, DSNS has a contract in place to allow for students from the Georgia Institute of Technology to collect motion and time study data during POD exercises. This service would be at no cost to the project area. Funds for this project are limited, so only a certain number of project areas will be able to participate at this time. For more information about this service, contact the DSNS Program Services Consultant for your project area.
CERA for RSS and distribution modeling:
DSNS has established a contract with the Center for Emergency Response Analytics (CERA) to obtain logistical modeling and simulation services for a limited number of jurisdictions with a population of over 500,000.
CERA has developed tools to evaluate a jurisdiction’s RSS capability, test operational alternatives, and measure RSS and distribution vulnerability to a variety of risk factors. CERA’s tools simulate the jurisdiction’s response to a bioterrorism attack, measuring the ability to provide PODs with an uninterrupted supply of materiel.
CERA explores operational alternatives by varying the number of POD deliveries and varying the number of pallets that are loaded on delivery trucks of different sizes. CERA simulates each alternative and selects the most promising for sensitivity analysis that measures vulnerability to risk factors such as:
A shortage of delivery trucks or drivers
Loss of a loading dock
Traffic
Use of non-professional crews in the RSS
Delays in the delivery of SNS materiel to the RSS
To date, CERA has modeled 36 CRI cities and MSAs. CDC contracted CERA to simulate the emergency distribution operations of 36 jurisdictions across the country. This is the RSS Analysis Project Final Report (exit). At present, no additional MSAs are being evaluated, pending the initial assessments. Please view the CERA Fact Sheet (PDF, 422k) for more information.
Modeling Forum (snsmodeling.org)
DSNS also maintains the SNS Modeling Forum (snsmodeling.org), a web site with the purpose of promoting the exchange of ideas, models and simulations designed to improve emergency response efforts and public health. The initial focus is on modeling the response efforts required in the aftermath of an aerosolized anthrax attack on a U.S. population; however dialogue is encouraged among all who are modeling various aspects of emergency response and other public health missions

6. Sharing and Improving Practices
Collaboration with partners
Federal Executive Board
ASTHO
NACCHO
Sharing promising practices
SNS ListServs (2)
SNS Extranet
SNS Mass Dispensing Satellite Broadcast Series
10 broadcasts since 2004
October 2009: Legal Issues
Continuing Education credits offered
Regional CRI/SNS Workshops
National SNS Training Summit
Fund NACCHO/ASTHO SNS Advisory Groups
Fund NACCHO’s STOCK-Box
MAD broadcasts
In January, we had our 10th in the series of MAD broadcasts. The next one is tentatively scheduled for October. The topic has yet to be determined and we want your input on it. We have a form in the back where you can include your suggestions. We are also working on getting continuing education credits for each of the past broadcasts in the series. So far, 5 in the series offer credits, but we should have 3 or 4 more by the end of the year.

7. Webinar Series Second Wednesday Webinars
Revolving Topics and Presenters
Archive available on SNS Extranet
Recent Topics:
Integrating SNS, PHEP, and HPP Exercises with HSEEP (May 11, 2011)
DEA Considerations in SNS Planning (April 2011)
Executive Order 13527: Updates on Federal Planning (March 2011)
Closed POD (February 2011)

8. Division of Strategic National Stockpile Deployable Teams
Stockpile Services Advance Group (SSAG)
Experts on Strategic National Stockpile response and state/local capability
Provides short-term technical assistance
Members represent DSNS at Emergency Operations Center, Incident Response Coordination Team, etc.
Receiving, Staging and Storing (RSS) Task Force
Assists with receipt, staging, onward movement and re-supply
Federal Medical Station (FMS) Strike Team
Helps state/local officials set up, re-supply and recover

9. Composite Measure
Address the need for more accurate preparedness and response indicator
Solution - link the functions and capabilities of dependent governmental sectors in the form of a composite measure
Medical Countermeasure Distribution and Dispensing (MCMDD) composite measure
Developed to serve as a collective indicator of preparedness and operational capability
Measure states, directly funded cities, Cities Readiness Initiative (CRI) planning jurisdictions, U.S. territories and freely associated states
Derived from results of state TARs conducted by DSNS staff, CRI TARs conducted by DSNS and state staffs, drill submissions, a single full-scale exercise, and compliance with programmatic standards

10. State by State Preparedness Report
Developed by CDC Office of Preparedness and Emergency Response (OPHPR)
Data and Content from DSNS, Division of State and Local Readiness (DSLR), and Division of Select Agents and Toxins (DSAT)
Provide visibility and measurability to Congress and the White House on the value of investments in preparedness
Relatable stories and successes are key to communicating our accomplishments and identifying our needs
Share your story with your SNS Program Services Consultant

11. Benefits Beyond Terrorism Response
10 years of SNS planning, training and exercise
Established nationwide capability to receive and dispense SNS MCMs
Benefits beyond this target capability:
Red River Flooding 2009 and Fargo, ND
Tactical communications plans, public information messaging, incident management team protocols and procedures, and distribution networks developed through CRI planning efforts used to coordinate successful evacuation, mass care and sheltering of thousands of citizens
2009 H1N1 Response - Nationwide
State and local health departments around the country utilized their CRI plans to receive, distribute and dispense H1N1 vaccines and antiviral drugs, and many MSAs reported using their plans to set up PODs for vaccination clinics, recruit volunteers, establish closed-POD partnerships and reach vulnerable populations.
Examples of state and local public health departments usage of Strategic National Stockpile plans to guide preparation and responses to real-world events or public health emergencies.
The Democratic National Convention in August 2008 (Denver-Aurora-Broomfield MSA) and the Republican National Convention (Minneapolis-St. Paul-Bloomington MSA) were each a 12-day national special security event coordinated by the U.S. Secret Service. The collaborative planning approach began more than a year prior between local, state and federal agencies to organize the implementation of public health incident management teams, the establishment of strike teams to coordinate and resource multiple point of dispensing (POD) sites, and the development of public information messages. This planning effort further strengthened partnerships between government and non-governmental agencies that have collaborated on CRI planning since The local health departments used this opportunity to effectively plan for CBRNE-type activities during these important national events.
Political National Conventions
Political and Special Events
The Miami-Fort Lauderdale-Pompano Beach MSA, in conjunction with Biowatch, used its CRI planning efforts to prepare for the 2010 Superbowl and Probowl in January and February 2010, respectively, in Miami, Fla. The 2010 Superbowl and Probowl – played a week apart – each attracted more than 70,000 fans.
Sporting Events
CRI planning for the Washington-Arlington-Alexandria MSA has facilitated collaboration between local health departments to plan for large-scale national events such as the inauguration of President Barack Obama in Washington, D.C. These planning efforts also have assisted in implementation for state funerals, marathons and other events in the region. CRI activities promote cross-jurisdictional planning for all-hazard emergency responses to include both private industry and government agencies such as the U.S. Department of Defense. CRI plans were put into action with hazardous materials responses during mercury spills in the District of Columbia school system when PODs were called down and staffed for collecting information and conducting testing. Additionally, CRI planning has helped provide a concept of operations to screen people who needed medications due to being placed in shelters during evacuations of high rise apartments and during the blizzard of 2010.
National Capital Region
Extreme flooding of the Red River in 2009 and 2010 forced the evacuation of thousands of citizens and vulnerable populations as well as those in health care facilities (hospitals, nursing homes). Local health departments in the Fargo MSA used their tactical communications plans, public information messaging, incident management team protocols and procedures, and distribution networks developed as part of their CRI planning efforts to coordinate the successful evacuation, mass care and sheltering of thousands of citizens on both the North Dakota and Minnesota sides of the Red River Valley region.
Red River Flooding
Natural and Man-made Disasters
American Samoa used parts of its SNS plan to respond to an earthquake and tsunami on September 29, The command center was already open for the H1N1 response, so island public health staff was able to easily transition to the tsunami response.
Pacific Earthquake and Tsunami
2008 Illinois Flooding
During the major flooding of 2008, Illinois used SNS plans to distribute needed supplies, such as bottled water, to areas of need. Regional distribution centers and the distribution network were used and the state was able to test the communications, inventory management and command and control functions of its SNS plan.
States along the New Madrid fault line are in preparations for a national-level, full-scale exercise, scheduled for May 2011, to test earthquake-related emergency response plans. For instance, Missouri will be exercising its local and state SNS plans at full scale across the state for the national exercise. The state’s RSS will be activated and SNS assets will be delivered to the affected areas with orders will be placed by HAMM radio operations. Missouri reports that it has the capability to conduct an exercise of this size as a result of the extensive SNS planning over the past years.
New Madrid Earthquake Exercise
Florida used SNS/RSS personnel to arrange hospital placement for the injured transportation in from Haiti. The state also used the procurement system and messaging/requesting system outlined in its SNS plan to arrange for goods and services for responder health and safety.
Haiti Earthquake
Florida used its SNS plan to guide its response to the Deep Water Horizon oil spill in In addition to using its procurement system and messaging/requesting system to secure goods and service for responder health and safety, the state also used its plan to procure caution signs for beaches. 
Deep Water Horizon Oil Spill
H1N1 operations dominated CRI activities for much of the past year. Most notably, relationships between state and local health departments and emergency management, fire rescue, and law enforcement grew stronger as PODs were planned and executed based on prior collaborative CRI planning.  State and local health departments around the country utilized their CRI plans to receive, distribute and dispense H1N1 vaccines and antiviral drugs, and many MSAs reported using their plans to set up PODs for vaccination clinics, recruit volunteers, establish closed-POD partnerships and reach vulnerable populations.
2009 H1N1 Response
Pandemics and Disease Outbreaks
In the National Capital Region, public health officials put CRI plans into action to call down and staff actual POD sites to collect information and provide testing during investigations of a tuberculosis outbreak.
Tuberculosis
Measles, West Nile, Valley Fever, Hepatitis
The Phoenix-Mesa-Glendale MSA has used its all-hazards approach to CRI planning to effectively respond to an outbreak of measles and hepatitis in 2009, an outbreak of Valley Fever and a current outbreak of West Nile Virus. In addition, the Phoenix-Mesa-Glendale MSA has used its CRI planning to execute childhood vaccination clinics in 2008 and 2009 and coordinate its seasonal flu vaccinations in 2009.
Providence-New Bedford-Fall River MSA used its CRI planning efforts to respond to a fatal mycoplasma infection in an elementary school student in Warwick, RI. The school where the event occurred was used as a POD to issue information to concerned parents, students and staff, which tested the public information strategy and POD setup portion of the CRI plan and helped restore faith that the school was safe for children to return.
Mycoplasma
In response to a mumps outbreak in a tradition-observant Jewish male boarding school in Pennsylvania, the Philadelphia Department of Public Health used its SNS plan to open and conduct a mass vaccination clinic to this closed population to limit disease transmission. The objectives of the clinic were to 1) vaccinate students and staff against the mumps and 2) estimate throughput rates for a vaccination operation with a two-vial mixing step to improve planning for a variety of future mass vaccination activities. In this closed population, 155 were vaccinated in 2.4 hours with no adverse effects.
Measles-Mumps-Rubella Mass Vaccination

12. Executive Order 13527

13. Executive Order 13527 Signed on December 30, 2009
Charged the federal government with establishing capability for the timely provision of medical countermeasures (MCM) following a biological attack
Three sections identified specific requirements
Section 2: US Postal Service delivery of MCM
Section 3: Federal rapid response
Section 4: Continuity of operations

14. EO 13527: Section 2 Postal Model
Collaboration with HHS and USPS since 2004
Proof of Concept Drills in
EO reaffirms support for postal model
Augments traditional PODs, does not replace
Critical requirement for execution: Security Planning

15. EO 13527: Section 3
Federal Rapid Response…develop the capacity to anticipate and immediately supplement the capabilities of affected jurisdictions to rapidly distribute MCM following a biological attack
Interagency effort evaluated requirements based on state/local gaps and federal capabilities
Three approaches identified:
Supplemental manpower
Federal closed PODs
Federal open PODs
Ongoing efforts to explore:
Supplemental manpower (including security)
Use of online medical screening to support PODs
Decreasing MCM deployment timelines

16. EO 13527: Section 4 Continuity of Operations
Protection of federal workforce to maintain government services
Interagency effort
Great challenges to overcome
Engagement of state and local leaders to leverage resources and integrate plans

17. PAHPA Reauthorization

18. PAHPA Reauthorization
Pandemic and All Hazards Preparedness Act
Signed in 2006
Being addressed by Congress this year
Draft bill currently working in House Energy and Commerce
CDC engaged with HHS, ASTHO, and NACCHO to identify needs
Proposals developed, reviewed and finalized through HHS
Participated in series of briefings to educate staff on Senate HELP Committee on key topics to PAHPA:
SNS
BARDA and Advanced Development of MCM
State and Local Perspectives

19. Novel Distribution and Dispensing Models

20. Innovative Approaches to Mass Dispensing: Examples from the States
Boy Scouts – used to deliver medication during an event.
CERT Door-to-Door Delivery
Closed POD (utilities, businesses, faith based organizations, military installations, etc.)
Drive through bank dispensing
Drive through POD's (colleges and Universities)
Grocery Store – used for dispensing

21. Innovative Approaches to Mass Dispensing: Examples from the States
Home Owner Associations - Fort Lauderdale (Broward County) use Home Owners Associations to facilitate mass dispensing to the public along with traditional POD models.
Large and Small closed PODs
Long Term Care Facility pharmacies – used for dispensing
Mass Transit Stations – dispensing
Mega POD - to facilitate mass dispensing in highly congested areas that is conducive to traffic grid-lock.

22. Innovative Approaches to Mass Dispensing: Examples from the States
Mobile POD trailers
Private physicians office Closed POD
Retail Pharmacy
School Bus Delivery
Tele-pharmacy dispensing operations
Tiered POD system (with most needed and highest population PODs opened first)
USPS Dispensing

23. Partnerships Between State and Local Health Departments and Department of Defense
Sample Partnership - North Dakota
Closed POD MOAs in place with Minot AFB and Grand Forks AFB. Agreements first brokered by state health officials, then involved local health departments. Agreements cover active duty military, contractors and family living on base. Air Force medical staff will operate the PODs.
Sample Partnership - Missouri
MOU is in place with Fort Leonard Wood. In addition, four local public health agencies are engaged in planning activities with Whiteman AFB.
AL Center for Emergency Response and Terrorism has initiated quarterly meetings with military and VA partners. Meetings include state and local public health agencies and cover a variety of planning topics, including interoperable comms and closed PODs for dispensing with federal military partners.

24. Case: Marriott Closed POD Pilot
DSNS conducting pilot project with Marriott hotels to establish closed PODs for hotel properties in local jurisdictions
16 local public health jurisdictions will be invited to participate, totaling 60 Marriott property locations
Current outreach to eight public health jurisdictions, totaling 37 property locations. Six of the eight jurisdictions agreed to participate, one decision is pending and one declined.
To date, most work has been done in Washington, D.C., and San Diego County, Orange County and Riverside County, CA

25. Case: Internal Revenue Service Closed POD Program
Objective
To assist the states in establishing multiple closed POD sites
To further enable the mass distribution of pill-form medicines during a regional or national emergency
To provide these necessary medicines as a service to IRS employees, IRS contractors, and their family members in an efficient and expeditious manner
To alleviate burden on public PODs
Authority
Homeland Security Presidential Directive-21 (HSPD-21) authorized CDC to partner with other federal agencies and the 50 states to establish open and closed PODs to dispense medicines during a declared national or regional emergency.

26. IRS Closed POD Overview
Can currently service 321,700 IRS employees, contractors and family members
104 IRS facilities across the country are planned to be serviced through the closed POD program
33 facilities actually serve as closed PODs
These 33 facilities also service an additional 71 IRS locations within commuting distance
IRS facilities with 500+ employees are targeted as actual closed POD sites

27. Developing Volunteer Capabilities
One time funding opportunity announcement
Pilot project between CDC/DSNS, state and local public health agencies
Fund a nationally recognized community volunteer and support organization to develop plans to recruit, train, and maintain volunteers
Support state and local public health agencies during a dispensing campaign
Create an exportable model that can be applied by other organizations and agencies
FOA open April 4th – June 4th, 2011

28. Challenges

29. Dispensing Challenges
Liability issues
PREP Act
Non-medical dispensing concerns
EUA Issues
Potential for delay in distribution
Staffing Issues
Volunteer pools
High turnover rate at state and local levels
Mandatory furloughs and work force reductions
Limited and shrinking funds
Logistics of achieving high throughput
Exercise Needs

30. Fiscal Challenges Reductions in PHEP funding
Adding requirements at the state and local level
Carrying the message:
State and local preparedness/state and local resources are key to effective response
OPHPR Director Ali Khan’s testimony to House Homeland Security subcommittee on 5/17/2011:
“Effectively using the SNS requires a collaborative effort by state, local, tribal, territorial, and federal partners on everything from MCM development to development of diagnostics to detection of an event to distribution and dispensing of MCM.”

31. Thank you www.cdc.gov/phpr/stockpile/stockpile