Appendix D

Commissioned Paper:
A Cost and Speed Analysis of
Strategies for Prepositioning
Antibiotics for Anthrax
1

James Guyton, Principal, PRTM, lead author

Robert Kadlec, Chandresh Harjivan, Shabana Farooqi, Sheana Cavitt, and Joseph Buccina, PRTM, co-writers and contributors

This paper was prepared by PRTM Management Consultants, LLC (PRTM) under a contract with the Institute of Medicine (IOM) and submitted in April 2011. This publication is limited to the approach and analysis described herein and on information available as of April 15, 2011. No representation or warranty (express or implied) is given as to the accuracy or completeness of the information contained in this publication, and to the extent permitted by law, PRTM and its members, employees, and agents do not accept any liability, responsibility, or duty of care for any consequences of the Committee or anyone else acting, or refraining to act, in reliance on the information contained in this publication or for any decision based on it.

INTRODUCTION

Currently, the United States Government (USG) stores the vast majority of its contingency medical countermeasures (MCM) in 12 centralized locations as part of the Centers for Disease Control and Prevention’s (CDC’s) Strategic National Stockpile (SNS); adopting the concept of prepositioning could alter this modus operandi. Prepositioning for public health preparedness is the placement and storage of MCM in caches that are geographically closer to the metropolitan areas and the corresponding populations at

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1This paper was commissioned by the Institute of Medicine (IOM) to provide background for the deliberations of the Committee on Prepositioned Medical Countermeasures for the Public. The responsibility for the content of this paper rests with the authors, and the paper does not necessarily represent the views of the IOM or its committees and convening bodies.



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Appendix D Commissioned Paper: A Cost and Speed Analysis of Strategies for Prepositioning 1 Antibiotics for Anthrax James Guyton, Principal, PRTM, lead author Robert Kadlec, Chandresh Harjivan, Shabana Farooqi, Sheana Cavitt, and Joseph Buccina, PRTM, co-writers and contributors This paper was prepared by PRTM Management Consultants, LLC (PRTM) under a contract with the Institute of Medicine (IOM) and submitted in April 2011. This publication is limited to the approach and analysis described herein and on information available as of April 15, 2011. No representation or warranty (express or implied) is given as to the accuracy or completeness of the information contained in this publication, and to the extent permitted by law, PRTM and its members, employees, and agents do not accept any liability, responsibility, or duty of care for any consequences of the Commit- tee or anyone else acting, or refraining to act, in reliance on the information contained in this publication or for any decision based on it. INTRODUCTION Currently, the United States Government (USG) stores the vast majority of its contingency medical countermeasures (MCM) in 12 centralized loca- tions as part of the Centers for Disease Control and Prevention’s (CDC’s) Strategic National Stockpile (SNS); adopting the concept of prepositioning could alter this modus operandi. Prepositioning for public health prepared- ness is the placement and storage of MCM in caches that are geographi- cally closer to the metropolitan areas and the corresponding populations at 1 Thispaper was commissioned by the Institute of Medicine (IOM) to provide background for the deliberations of the Committee on Prepositioned Medical Countermeasures for the Public. The responsibility for the content of this paper rests with the authors, and the paper does not necessarily represent the views of the IOM or its committees and convening bodies. 241

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242 PREPOSITIONING ANTIBIOTICS FOR ANTHRAX risk. The primary goal of prepositioning is to increase the speed of MCM distribution and dispensing during a high-consequence biological incident. In the event of an attack with aerosolized Bacillus anthracis (anthrax), administering oral antibiotics immediately following exposure has demon- strated the potential to save lives (Friedlander et al., 1993). Anthrax exists in vegetative and spore forms. The spore is an extremely hardy, dormant form of the bacterium; it can persist for decades in the environment. When a spore enters a live host, it transforms into its vegetative, disease-causing state. Once active, anthrax produces toxins that are lethal. Given its high lethality and potential ease of acquisition, production, and dissemination, the release of aerosolized anthrax is the type of high-consequence biological attack that is of most concern. The Center for Biosecurity at the University of Pittsburgh Medical Center notes that anthrax is considered one of the most serious bioterror- ism threats for the following reasons (UPMC Center for Biosecurity, 2007): • widespread availability of starter cultures in culture collection banks around the world; • widespread natural availability in endemic areas; • wide commercial availability of equipment and techniques for mass production and aerosol dissemination; • robustness of anthrax spores, making anthrax easier to weaponize for aerosol dissemination than other biological agents of concern; • high fatality rate in untreated inhalational cases; • relatively low infectious dose, based on nonhuman primate animal data; • risk of antibiotic-resistant strains that exist in nature or that may be easily cultivated for use in an intentional release; and • recent use of anthrax during the 2001 Amerithrax attacks. During the 2001 Amerithrax attacks, the median incubation time for inhalational anthrax was 4 days (Jernigan et al., 2001). It is estimated that if oral antibiotics are not administered before the onset of clinical symp- toms, the mortality rate, even in intensively treated cases, could potentially exceed 90 percent (UPMC Center for Biosecurity, 2007). In the few inhala- tional anthrax cases treated in 2001, intensive clinical treatment resulted in a mortality rate of 45 percent (Jernigan et al., 2001). Depending on the ini- tial infective dose and when the exposure is detected, the effective window for antibiotic administration may be considerably less than 96 hours. As a matter of USG policy, current requirements have set the objective of deliv- ery of oral antibiotics to potentially exposed individuals within 48 hours of the decision to do so (CDC, 2010a). Prepositioning can enable more rapid dispensing of oral antibiotics following an anthrax attack, thus increasing

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243 APPENDIX D the likelihood that a larger proportion of infected individuals will receive antibiotics during the asymptomatic incubation period. The Institute of Medicine’s (IOM’s) Committee on Prepositioned Medi- cal Countermeasures for the Public commissioned this paper to provide background for its deliberations on prepositioning strategies for anthrax antibiotics. PRTM analyzed three prepositioning strategies: • caches in hospitals and pharmacies; • caches in workplaces of different types (e.g., state and local gov- ernment, private infrastructure, Fortune 50 companies, small busi- nesses), schools, universities, daycare centers, and institutional facilities for older adults (for simplification, the PRTM team cat- egorized these into large and small places of work); and • approved MedKits (or similar dose packs) stored in individual households and intended for use by occupants. This paper focuses largely on two variables: the cost of each preposi- tioning strategy, and the time to antibiotic distribution and dispensing. The paper also examines the implications of these strategies in three different settings: urban, suburban, and rural. PRTM chose the Minneapolis-St. Paul metropolitan statistical area (MSA) as a case study because of the avail- ability of relevant cost and delivery time data and its confluence of urban, suburban, and rural environments. The prepositioning strategies are com- pared with two scenarios: • The current approach of SNS to receiving, storage, and staging (RSS) sites to points of dispensing (PODs)—This approach serves as the baseline model. • The postal distribution model—In 2008, federal health officials announced the beginning of a postal distribution pilot project in the cities of Minneapolis and St. Paul (Roos, 2008). In this model, postal workers deliver antibiotics directly to individuals’ homes in the event of an anthrax attack. Other approaches also are considered in the section below on alterna- tive dispensing strategies, including a forward-deployed SNS model and vendor-managed inventory. In addition, in the course of this effort, PRTM uncovered several areas for additional consideration, which are highlighted in a later section. Note that detailed data on which the discussion of the various dispensing strategies is based are presented in Appendix D.1. In conducting research for this paper, PRTM performed an extensive review of open-source literature and interviewed more than 40 subject mat- ter experts. Appendix D.2 provides a list of interviewees.

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244 PREPOSITIONING ANTIBIOTICS FOR ANTHRAX STRATEGIES FOR PREPOSITIONING This section provides a brief background on CDC’s current strategy for distribution and dispensing of antibiotics and a description of each prepo- sitioning strategy. The current approach, based on PODs, is the standard, practiced model for delivering MCM, such as oral antibiotics and vaccines, to an impacted locale following a biological attack. This model is the back- bone of several MCM dispensing strategies that were reviewed. Whereas the prepositioning strategies are intended to increase the speed with which a 10-day supply of oral antibiotics is delivered, they are intended only as an adjunct to the POD dispensing approach. The SNS-RSS-POD approach serves as the principal means to distribute and dispense the remainder of the full 60-day course of antibiotics, and vaccination as necessary, to all those affected. Current Approach for Distribution and Dispensing: Points of Dispensing The current distribution and dispensing model (Figure D-1) is managed by CDC in conjunction with state, local, and tribal health departments. Antibiotics and other MCM are stored in 12 undisclosed locations across t he United States in the SNS. The exact amount of antibiotics stored in these caches is not made public, for security reasons. In the event of an attack, CDC guarantees the delivery of a “Push Package” of medical mate- rial, including oral antibiotics, to the affected location within 12 hours of a request (CDC, 2010b). A Push Package is a large package of medications and other medical supplies that can be transported quickly from one of the SNS locations. The oral antibiotics (approximately 500,000 doses in the Push Package) are intended to be an initial supply. Additional quanti- ties of oral antibiotics are transported to the area from a larger reserve contained in a vendor-managed inventory, or inventory controlled by the manufacturer that is guaranteed to be available to the federal government upon request. Once the Push Package has been transported from the SNS, state authorities receive it at a predesignated RSS site. At this point, the MCM are transitioned from federal to state control. The RSS staff unpacks the FIGURE D-1 Strategic National Stockpile (SNS) to receiving, storage, and staging (RSS) sites to points of dispensing (POD) model. NOTE: The star denotes where the antibiotics are stored.

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245 APPENDIX D medications and transfers them to trucks, which are bound for individual PODs. The amount of antibiotics delivered to each POD is predetermined by the estimated number of people to be served by each. Once the antibiotics reach the PODs, they may remain under state control or be turned over to local (county or city) control, depending on the jurisdiction. Although the conceptual approach was developed by CDC, the PODs’ actual operation and staffing are determined by the state or local jurisdiction. At the PODs, public health practitioners screen the public for contraindications to the antibiotics, educate them on the use of the antibiotics, and then dispense a 10-day supply to each person. Different jurisdictions employ a variety of approaches to increase throughput, such as having the head of the household retrieve drugs for everyone in that house- hold, as one interviewee from Tennessee indicated, or having the necessary paperwork completed before a potential event to avoid time spent filling out forms during an emergency, as an interviewee from New York noted. Caching in Hospitals and Pharmacies Prepositioning contingency antibiotics in hospitals and pharmacies (Figure D-2) would effectively result in increasing the on-hand antibiotic supply beyond current inventories for routine use in such facilities. Gen- erally, hospitals and pharmacies stock enough antibiotics to meet their immediate daily needs. They rely on distributors to continuously provide “just in time” supplies of antibiotics so they have enough stock to fill their needs, but not so much that they have extra stock on hand. Notable e xceptions to this practice are Department of Veterans Affairs (VA) hospitals, Department of Defense (DOD) medical treatment facilities, and some private hospitals that maintain a limited stockpile to provide to their staff and patients in the event of a biological attack. Expanding this practice to all hospitals, and possibly clinics, would require significant increases in their stock on hand and the costs associated with excess inventory. While they would likely still use the first-in/first-out FIGURE D-2 Hospital/pharmacy prepositioning model. NOTE: The stars denote where the antibiotics are stored.

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246 PREPOSITIONING ANTIBIOTICS FOR ANTHRAX approach to lessen the impact of expiry, actual costs associated with expiry would depend on the ratio of the size of the cache to the turnover volume of routine use of the antibiotics. While hospitals, clinics, and pharmacies could maintain contingency antibiotic stockpiles, the manner in which those institutions could dispense such products would be significantly different. Hospitals would serve only as closed PODs. A closed POD is a location that is not open to the general public, but is set up to serve a predefined population. Hospitals would provide prophylactic antibiotics only to patients, staff, and families of staff. This practice would increase the likelihood that essential hospital workers would report for duty. Limiting dispensing to hospital personnel would be intended to maintain operations for treating current patients and those who needed treatment during the emergency. This dispensing strategy would not accommodate the general public, who, if they sought such treat- ment, would likely inundate the facility and possibly render it incapable of performing its essential functions. In contrast, pharmacies and some clinics could serve as open PODs. They would be able to dispense antibiotics to the general public during an emergency. One advantage of this model is that pharmacies and clinics are numerous and have high prevalence in the United States, and people have a general familiarity with the location of their local pharmacy or neighbor- hood clinic. This approach, however, would require that pharmacies rapidly package antibiotics for swift dispensing, as opposed to routine operations whereby prescriptions are filled on an ad hoc basis. Hospitals, pharmacies, and some clinics already have some security measures in place for safeguarding medications, so during nonemergencies they likely would not incur an incremental security cost. However, in the event of a biological attack, additional security would likely be necessary to augment existing security activities during dispensing operations. Hos- pitals, clinics, and pharmacies also would have medical staff on hand who would be licensed to dispense antibiotics and could conduct the necessary prescreening of patients. Caching in the Workplace Prepositioning in workplaces (Figure D-3) would effectively create additional closed PODs. In this approach, private companies would stock enough antibiotics to dispense to their employees during an emergency. It would be the company’s decision whether to also provide antibiotics to em- ployee families. The manner by which private companies could participate is two-fold. They could purchase and store antibiotics on site themselves, or they could identify themselves to local public health authorities to serve as a closed POD. In the latter case, the local authorities would provide the

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247 APPENDIX D FIGURE D-3 Workplace prepositioning model. NOTE: The stars denote where the antibiotics are stored. antibiotics to the workplace by way of the SNS. The former approach, prepositioning on site, would offer the advantage of decreasing the time to dispensing. Serving as a closed POD would not necessarily increase speed over the baseline because no prepositioning would be taking place, and the delivery of antibiotics to the workplace would be contingent on the speed of delivery of the SNS assets. Caching in workplaces would effectively decrease the percentage of the population that would have to be serviced by public PODs. Employees would benefit from being able to access antibiotics from a familiar place. However, workplaces would likely need to bring in medical personnel for screening and dispensing if they did not already have medically trained personnel on site. Alternatively, the workplace could conduct prescreen- ing of personnel before the event, a practice that was performed in one interviewee’s workplace. This approach might allow the antibiotics to be dispensed by nonmedical personnel following an anthrax incident. Caching in the Home (MedKits) Prepositioning antibiotics in the home would entail providing MedKits to a predefined segment of the population within a certain area (Figure D-4). In lieu of a Food and Drug Administration (FDA)–approved MedKit or an over-the-counter product, a prescription would be required for each recipi- ent’s doctor, or recipients would have to be subject to some screening by a health care worker before the MedKits could be issued. This approach would involve screening every person prior to dispensing to determine contraindications, such as allergies, and dosing changes. The appropriate type and numbers of bottles of antibiotics would then be shipped to every household. These bottles would be encased in plastic bags with instruc- tions on storage and use of the antibiotics. Each bag would contain enough antibiotics to cover each person in the household for 10 days. Figure D-5 shows a depiction of a home MedKit.

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248 PREPOSITIONING ANTIBIOTICS FOR ANTHRAX FIGURE D-4 Home MedKit prepositioning model. NOTE: The star denotes where the antibiotics are stored. USPS = U.S. Postal Service. FIGURE D-5 Depiction of a home MedKit. SOURCE: CDC, 2008. CDC conducted a study in which it dispensed MedKits to a predefined population in St. Louis to determine how MedKits would be handled and whether people would appropriately follow the instructions provided (CDC, 2008). It was found that the large majority of the population (97 percent) did not use the antibiotics inappropriately and returned the MedKits intact. The study also showed that people had a generally posi- tive response to the MedKits and felt more prepared having one in the home.

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249 APPENDIX D The advantage of this model is speed of dispensing in response to an event. The public could be alerted and begin taking the antibiotics immediately without needing to leave their homes. However, many vari- ables could impede the effectiveness of this model. These include little or no medical oversight of prescription medications, loss of the medication, incorrect storage, compliance and tampering, product expiry and returns, and inappropriate usage during other periods of illness. Because of the risk of antibiotic-resistant strains of anthrax, moreover, it could be necessary to have multiple types of antibiotics in the MedKit, which would further complicate the use of this approach. Postal Distribution Model One additional model used in this study for comparison is the postal distribution model (Figure D-6). This model is a variation on the standard SNS-RSS-POD model. Rather than the pull approach of that model, the postal distribution model serves to push MCM out to the population. The pilot for this model was sponsored by the Cities Readiness Initiative (CRI) and was employed in the Minneapolis-St. Paul MSA. In this model, the medications are shipped from the SNS to the RSS, as in the standard model. From there, the medications are delivered to the postal service rather than to PODs. The medications are then delivered to residences in the affected area by postal workers, who agree to deliver the antibiotics on a volunteer basis. In exchange, they are given one MedKit for their home and one for work to cover them and their families. During an emergency, the postal workers would report to the postal service and receive enough MCM to cover approximately two normal routes, as well as a security escort. They would then deliver one bottle of antibiotics to each household on the predetermined routes (Plessas, 2010). As the postal workers cover these routes every day, they are trained to make these deliv- eries and have done so with efficiency in limited-scope trials in Seattle, Boston, and Philadelphia. FIGURE D-6 Postal distribution model. NOTE: The stars denote where the antibiotics are stored. USPS = U.S. Postal Service.

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250 PREPOSITIONING ANTIBIOTICS FOR ANTHRAX ANALYTICAL FRAMEWORK PRTM used the analytical framework shown in Figure D-7 to compare the above dispensing models. In conducting the analysis, the PRTM team sought to compare the different prepositioning strategies included within the scope of this paper with the current SNS-RSS-POD baseline. To accom- plish this, the team estimated total costs associated with: • product, • transport, • inventory management, and • dispensing. For each dispensing strategy, the team examined the time required to dispense antibiotics from the cache to the subset of the population served, as well as the total time required to dispense antibiotics to the general pub- lic using a combined SNS-RSS-POD and prepositioned cache strategy. By measuring the SNS-RSS-POD baseline, the team was able to estimate time savings over the baseline, as well as time savings per dollar spent for each prepositioning strategy. It is important to note that the time savings referenced above apply to the subset of the population served by the various prepositioning strate- gies. According to a Georgia Institute of Technology study, 20 percent participation by the private sector is a reasonable goal, taking into con- sideration anticipated reluctance to participate (Lee, 2011). As a result, the team estimated that 20 percent of the population would receive an Current SNS-RSS-PODs baseline, with comparison to prepositioning strategies Administration # required to Cost to cache Time to Time savings Strategy administer to (build and manage administer to over baseline population stockpile) per population capita (throughput) — SNS-RSS-PODs (baseline) Minneapolis- Hospital and St. Paul pharmacy caches population : Comparison across strategies 1,700,000 Workplace caches Home caches (MedKits) FIGURE D-7 Analytical framework.

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251 APPENDIX D initial dose of MCM through prepositioned caches at workplaces or hospitals/pharmacies, while the remaining 80 percent would still need to receive MCM through PODs. For those scenarios, referenced time savings are therefore applicable only to the 20 percent of the population that would receive MCM through the prepositioned caches. In addition to enabling initial time savings, prepositioned caches would help alleviate the burden on PODs by decreasing the total number of individuals that would visit PODs to receive their initial dose of MCM. To allow for additional analysis and comparison, the team reviewed cost and speed implications associated with employing the postal model in the Minneapolis-St. Paul MSA. To facilitate an accurate comparison, the team assumed the same treatment and dosage as planned for the postal model (consisting of an initial treatment course of 10 days, with two pills per dose), as well as the same target population (the Minneapolis-St. Paul postal plan is intended to serve residents in 20 zip codes, with a combined population of 1.7 million individuals), according to estimates provided by interviewees. COMPONENTS OF COST AND SPEED FOR DISPENSING STRATEGIES PRTM assessed each strategy by taking into consideration three key variables: (1) total population served, (2) total cost, and (3) total speed of dispensing. The following sections decompose the general methodology employed by the team, including major assumptions, to derive the estimated population, cost, and speed for each strategy assessed. Additional detail on these calculations can be found in Appendix D.1. Total Population Served Both total cost and speed will vary greatly depending on the expec- tation of the total population to be served by each dispensing location. Table D-1 lists the PRTM team’s assumptions related to estimating the population served.

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TABLE D.1-6 308 Continued Postal Component     Description Data Calculations   Dispensing   Dispensing - Labor - Postal workers [(2,540 workers × 8 hours × 23.72/hr) + $843,483.20 (2,540 workers × 4 hours OT wage [1.5 regular])] - 332.08 per worker Dispensing - Administrative Fees/Operational Costs $23,000 per zip × 20 zip codes (source: $460,000 Interview with federal official) Dispensing - Security (per officer) $406.16 12 hour shift, 8 regular/4OT, for MnSP using BLS rate of $29.01/hr Dispensing - Security needs (# of officers) 2,540 2/3 (volunteer rate) × 3,810 (total USPS carriers in MnSP) - (source: interview with federal official) Dispensing - Security (total) 2,540 × $406.16 $1,031,646.40 (Labor - postal workers) + (Dispensing - Dispensing - Total Costs $2,335,129.60 Administrative Fees/Operational Costs) + (Dispensing - Security)   Inventory Management   Inventory Management - Labor     Inventory Management - Cost of Storage/Pallet     Inventory Management - # of Bottles/Pallet     Inventory Management - # of Pallets Required     Inventory Management - Storage (total)         Inventory Management - Total Costs (excluding replenishment costs)

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Postal Component     Description Data Calculations Inventory Management - Replenishment - Total Costs     for Medication (total postal dispensing) Inventory Management - Replenishment - Total Costs $42,655.74 [2,540 workers × 2.28 MedKits (for for Postal Workers’ MedKits household) × $5.12 per MedKit] + [2,540 workers × 1 MedKit (for work) × 5.12 per MedKit] Inventory Management - Replenishment - Total Costs     for Product Purchase (overall) Inventory Management - Replenishment - Labor - $0.00   Postal workers Inventory Management - Replenishment - Security $0.00   (total) Inventory Management - Replenishment - Total Costs $0.00   for Dispensing Inventory Management - Replenishment Costs     (total)   Dispensing Time   Dispensing Time - Postal Dispensing (hours) (source: interview with federal employee 12 and Georgia Tech paper) Dispensing Time - SNS to RSS to Postal Office (source: calculations derived from 13.24 Transportation (hours) presentation - G. Burel. An SNS Perspective on Pre-positioning Medical Countermeasures. Centers for Disease Control and Prevention, February 28, 2011. Presented to IOM Committee on Prepositioned Medical Countermeasures for the Public) 309 continued

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TABLE D.1-6 310 Continued Postal Component     Description Data Calculations Postal Dispensing (hours) + SNS to RSS Dispensing Time - Total (hours) 25.24 to Postal Office Transportation (hours) Total Costs - Postal (43.82%, 745,000 doses/     households) Product Purchase Price     Transportation $0.00   Dispensing $2,335,129.60   Inventory Management       Total Cost (without replenishment) $3,495,285.34   Replenishment Costs (annual)   POD Component Data Calculations Costs     Individuals 955,000   Households 418,859.65       Product Purchase Price Product Purchase Price - Costs per daily dosage     - Propylaxis, Doxycycline Product Purchase Price - Additional Medication Costs     Per Daily Dosage (packaging, etc.) Product Purchase Price - Total Costs for Medication     Per Daily Dosage

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POD Component Data Calculations Costs     Product Purchase Price - Total Costs for Medication     (per household)   Product Purchase Price - Total Costs for Medication   (overall)   Transportation   Transportation - SNS to RSS to Postal Office N/A not available not available Transportation Costs (overall) $0.00   Dispensing   Dispensing - Labor - Salaries (per POD, per day) $44,736.00 300 staff per POD/day (source: interview with state department of health official) × 8 hours/day × $18.64/hr (source: Zaric et al.) Dispensing - Labor - Salaries (20 PODs, per day) $894,720.00 Labor per day per POD × 20 PODs Dispensing - Labor - Salaries (total) 20.94 hours × 1 day/24 hours × $780,643.20 $894,720/day Dispensing - Labor - Training (annual) 300 staff per POD × 8 hours of training/ $894,720.00 yr × $18.64/hr Dispensing - Administrative Fees/Operational Costs $5,000.00   (daily, per POD) Dispensing - Administrative Fees/Operational Costs $100,000.00 $5,000 × 20 PODs (daily, 20 PODs) Dispensing - Administrative Fees/Operational Costs 20.94 hours × 1 day/24 hours × $87,250.00 (total) $100,000/day Dispensing - Security (daily, per POD) $2,784.96   Dispensing - Security (daily, 20 PODs) $55,699.20   311 continued

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TABLE D.1-6 312 Continued POD Component Data Calculations Costs     Dispensing - Security (total) 20.94 hours × 1 day/24 hours × $48,597.55 $2,784.96/POD per day × 20 PODs Labor-salaries (total) + labor-training Dispensing - Total Costs $1,811,210.75 (total) + security (total)   Inventory Management   Inventory Management - Labor     Inventory Management - Cost of Storage/Pallet     Inventory Management - # of Bottles/Pallet     Inventory Management - # of Pallets Required     Inventory Management - Storage (total)         Inventory Management - Total Costs (excluding replenishment costs) Inventory Management - Replenishment - Product     Purchase (overall) Inventory Management - Replenishment -     Transportation (overall) Inventory Management - Replenishment - Dispensing     (overall)     Inventory Management - Replenishment Costs (total, SLEP)   Dispensing Time   Dispensing Time - SNS to RSS to Postal Office (source: CDC presentation) 13.24 Transportation (hours)

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POD Component Data Calculations Costs     Dispensing Time - POD Operating Time (hours) 418,859.65 households/20 pods × 20.94 1 hr/1,000 households SNS to RSS to Postal Office Dispensing Time - Total (hours) 34.18 Transportation + POD Operating Time Total Costs - POD (56.18%, 955,000 doses/     individuals, 418,859.65 heads of household) Product Purchase Price     Transportation   $0.00 Dispensing   $1,811,210.75 Inventory Management (without replenishment)       Total Cost (without replenishment) $3,345,180.35   Replenishment Costs (SLEP)   Total Costs - Postal Component + POD Component     Product Purchase Price     Transportation $0.00   Dispensing $4,146,340.35   Inventory Management     Total Cost (without replenishment) $6,919,617.69   $42,655.74   Replenishment Costs (annual)     Replenishment Costs (SLEP)     Replenishment Costs (annual + SLEP)     Total Dispensing Time for Strategy 313 continued

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TABLE D.1-6 314 Continued POD Component Data Calculations Costs     Dispensing Time for Postal Component (hours) 25.24   Dispensing Time for POD Component (hours) 34.18   Rate-Limiting Step (hours) 34.18   Total Dispensing Time for Strategy (hours) 34.18  

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Appendix D.2 Authors, Acknowledgments, and Interviewees AUTHORS AND ACKNOWLEDGMENTS James Guyton is the lead author of this paper. The following PRTM employees served as co-writers or contributors to this effort: • Dr. Robert Kadlec • Dr. Chandresh Harjivan • Shabana Farooqi • Sheana Cavitt • Joseph Buccina PRTM enjoyed the privilege of working with the Institute of Medi- cine (IOM). PRTM would like to thank Clare Stroud, who served as an immensely helpful point of contact. PRTM expresses its gratitude to the Committee on Prepositioned Medical Countermeasures for the Public for the opportunity to contribute to its mission. PRTM would also like to thank Kristin Viswanathan for her assistance with the document review and all IOM employees that contributed to this effort. PRTM interviewed more than 40 subject matter experts on this topic. The team would like to thank each of them for their time and their keen insights. 315

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316 PREPOSITIONING ANTIBIOTICS FOR ANTHRAX INTERVIEWEES The following is a list of individuals who were interviewed by PRTM for the purposes of this paper. Affiliations listed reflect the individual’s pri- mary association as of the date of the interview. Sid Baccam, Innovate Emergency Management, Inc. Mike Berzig, Department of Veterans Affairs Tara Blackley, Virginia Department of Health Joseph Canzolino, Department of Veterans Affairs Norm Coleman, Department of Health and Human Services (HHS), Assistant Secretary for Preparedness and Response (ASPR), Office of Policy and Planning (OPP) Susan Cooper, Tennessee Department of Health Victoria Davey, Department of Veterans Affairs Adele Etheridge, Office of Public Health Preparedness and Response, Centers for Disease Control and Prevention (CDC) Matthew Feltman, Kroger/Giant Sue Gorman, Office of Public Health Preparedness and Response, CDC Jayne Griffith, Minnesota Department of Health Roy Herman, Office of Public Health Preparedness and Response, CDC Laura Herrera, Department of Veterans Affairs Jack Herrmann, National Association of County and City Health Officials (NACCHO) Mary Beth Hill-Harmon, HHS/ASPR/Biomedical Advanced Research and Development Authority (BARDA) Jeffrey Holmes, PRTM Nathaniel Hupert, CDC and Weill Medical College, Cornell University Terrie Kolodziej, HHS/ASPR/BARDA Lisa Koonin, CDC George Korch, HHS/ASPR Joe Larsen, HHS/ASPR/BARDA Eva Lee, Georgia Tech University Aggie Leitheiser, Minnesota Department of Health Rebecca Lipsitz, HHS/ASPR Rich McNally, HHS/ASPR Carter Mecher, National Security Staff Matthew Minson, Texas A&M University Amanda Fuller Moore, North Carolina Department of Health and Human Services Stephen Morris, HHS/ASPR/BARDA Chris Motsek, Office of Public Health Preparedness and Response, CDC Paul Peterson, Tennessee Department of Health

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317 APPENDIX D Jude Plessas, U.S. Postal Service Ken Rapuano, The MITRE Corporation Marjorie Sidebottom, University of Virginia David Starr, Office of Emergency Preparedness and Response, New York City Department of Health and Mental Hygiene Jason Stear, Office of Public Health Preparedness and Response, CDC Thomas Tighe, Direct Relief International Penny Turnbull, Marriott Hotels International James Turner, American College Health Association Representative, Utility Services Provider Michael Valentino, Department of Veterans Affairs

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