[Page numbers followed by b, f, n, or t refer to boxed text, figures, footnotes, or tables, respectively.]
A
Accountability
importance of, 165, 166
recommendations for, 12, 170, 209-210
Adherence to prophylactic antibiotic regimen
adverse events and, 131
concerns with predispensing strategies, 138
as determinant of prepositioning strategy effectiveness, 181
evidence, 84, 121, 128-130
Adverse events, 75, 130-132, 173
Al Qaeda, 23
Allergic reactions, 75, 132, 142-143
Alliance for Prudent Use of Antibiotics, 132
American Media Inc., 57
American Pharmacists Association, 108
Amoxicillin, 42, 131
Anthrax attack
animal models for studying effects of, 54-55
current state of response readiness, 2-3
danger of, 5, 23-24
data sources for MCM planning, 34-35
historical experience in the United States, 23, 24, 47, 48t, 56-57, 84, 125, 131
lethality, 23, 24-25, 41, 55
potential scenarios, 174-175
public health challenges, 1, 2, 21
See also Antibiotic prophylaxis, post-exposure; Prepositioning of anthrax countermeasures; Risk of anthrax attack
Anthrax vaccine adsorbed, 32, 42
Antibiotic prophylaxis, post-exposure animal studies, 55
approved agents, 5, 42
challenges in responding to aerosolized anthrax attack, 21
constraints on effectiveness of, 5-7
determinants of effectiveness, 13-14, 41
emergency use authorization, 86
expiration of medications, 85, 88, 114-115, 116
goals for timely distribution, 7, 21, 58, 61
impact of time to detection on, 57-61
incubation period of anthrax and, 6-7, 46, 55-57, 61
mechanism of action, 33
recommendations for research, 19, 215
response to anthrax attacks of 2001, 56-57
salient issues, 41
storage of medications, 114
treatment regimen, 42, 133
See also Adherence to prophylactic antibiotic regimen; Antibiotic- resistant anthrax
Antibiotic-resistant anthrax concerns with predispensing strategies, 132-133, 134-135, 136
creation of, 5, 43, 132-133
definitions, 43n
flexibility of MCM system, 45, 46
implications for MCM planning, 5-6, 32, 43-46
laboratory testing for, 44b, 45n
threat of, 24, 43, 44b
Antitoxin strategies, 26, 33
Appropriateness of prepositioning strategies, 14, 15t, 199-202, 200t
Assessment of distribution and dispensing capacity
data from full-scale exercises, 162-163
in decision-aiding framework for prepositioning, 10b, 154b, 158-163
importance of, 10, 163
measures for, 10, 11, 25, 159-161, 164, 212
obstacles to, 10-11, 158, 163
recommendations for, 11, 164, 212
Assistant Secretary for Preparedness and Response, 108, 156
Association of State and Territorial Health Officials, 108
Aum Shinrikyo, 23
B
BioWatch Actionable Result, 59
BioWatch monitoring system, 35, 58-60
Brentwood postal facility, 56, 84
Business Executives for National Security, 77
C
Cached MCM
advantages, 95-97t
appropriateness and consequences of, 15t, 199-202, 200t
definition, 7, 8f, 29b, 93
determinants of effectiveness, 13
in educational institutions, 118-119
in hospitals and health care facilities, 26, 103-106
infrastructure needs, 95-97t
key features, 94, 95-97t
organizational entities needed for, 95-97t
potential health risks, 172
potential locations, 103
private sector participation, 107
recommendations for local jurisdictions, 14-16, 18b, 203, 211
role of community- and faith-based organizations, 117-118
See also Home storage of antibiotics; Personal stockpile; Workplace caches
Centers for Disease Control and Prevention
Cities Readiness Initiative, 7, 53b, 58, 61, 73
classification of anthrax as bioterrorism agent, 24
Countermeasure Inventory Tracking program, 108
in development of guidance on public-private coordination, 110
measures of state and local dispensing capacity, 25, 159-160
postexposure antibiotic regimen recommended by, 42
Public Health Emergency Preparedness Cooperative Agreement, 105, 161, 162-163
recommendations for, 11, 164, 212
support for full-scale exercises, 162-163
See also Strategic National Stockpile
CHEMPACK Program, 71n, 100-101, 100b
Children
anthrax postexposure treatment regimen, 42
consideration of, in public health planning, 34, 167
dosing concerns with predispensed antibiotics, 135
risk of unintended ingestion of antibiotics, 133
Ciprofloxacin, 5, 42, 88, 114, 131
Cities Readiness Initiative, 7, 53b, 58, 61, 73
Communications
challenges in predispensing strategies, 136-138
importance of, 83, 136
instructions for use of predispensed medications, 137
POD information, 85, 104
for push strategy implementation, 78
recommendations for research, 19, 215
SNS: Supply Chain Dashboard for, 108
strategic planning for MCM dispensing, 83-84
Community Emergency Response Teams, 118
Community health centers, 105-106
Community organizations, 117-118
Consequences of anthrax attack, as risk assessment component, 155, 156
Costs
annual inventory maintenance, 193-194
components of, in prepositioning, 173, 191-193
consideration of, in decision-aiding framework, 10b, 154b, 173
to dispense MCM, 194-195
ethical decision making in public health, 166
evaluation of prepositioning strategies, 13, 173
expiration of medications, 88, 102
FDA-approved MedKit development, 141-142, 195-197, 199
forward deployment by Strategic National Stockpile, 99-100
full-scale distribution and dispensing exercises, 162
initial stocking, 193
multidrug strategies, 135
recommendations for evaluation of, 13, 202-203, 210-211
recommendations for research on, 19, 214-215
See also Health benefits and economic costs of prepositioning
Countermeasure Inventory Tracking program, 108
Critical infrastructure personnel definition, 28b
Executive Order on, 33
need for special consideration of, 197
predispensed MCM for, 139-142, 198-199
prepositioning strategies for, 198
risk of inappropriate use of predispensed antibiotics, 141
Cutaneous anthrax, 41, 60
D
Data sources for MCM planning animal studies, 54-55
anthrax incubation period, 46-47
current limitations, 34-35
drills and exercises, 162-163
ethical obligations to improve, 165
from H1N1 influenza pandemic response, 163
Department of Defense, 26
forward deployment of MCM at facilities of, 101
Department of Health and Human Services, 26
in emergency response system, 72, 86, 87, 108
recommendations for, 9, 19, 112, 211, 214-215
Department of Homeland Security, 5, 24, 26, 155, 156, 163
BioWatch monitoring system, 35, 58-60
Department of Justice, 26
Detection and surveillance system capabilities assessment, in decision- aiding framework, 10b, 154b, 157
case reports in, 60-61
as component of national security strategy, 26
cutaneous disease, 60
as determinant of dispensing system effectiveness, 187
environmental sensors, 58-60
impact on post-exposure prophylaxis, 57, 62
implications for dispensing decisions, 35, 85
mechanisms, 58
prophylaxis distribution and, 7
recommendations for capability assessment, 12, 18b, 202-203, 210-211
role of clinicians and first responders, 81
Diethylene triamine pentaacetic acid, 101
Disposal of antibiotics, 133-134, 193
Distribution and dispensing system capacity assessment, 10-11, 25, 35, 158-163
current concerns and shortcomings, 2-3, 24-25, 36, 82-85, 89
current goals, 7, 21, 58, 61
current structure, 69-71, 88-89
determinants of effectiveness of, 187-199
implications of antibiotic-resistant anthrax, 44-45
local dispensing capability as rate-limiting factor in attack response, 187-188
need for national guidance on public-private coordination, 109-111, 111b private sector participation, 9, 107, 108-109
public behavior as determinant of effectiveness of, 181, 188, 214t
recommendations for local jurisdictions to improve, 14-16, 18b, 203, 211
recommendations for national guidance on public-private coordination, 9, 18b, 112, 211
response to H1N1 influenza pandemic, 25
role of clinicians and first responders, 81
strategies for, 7. See also specific strategy
terminology, 28b
See also Medical countermeasures (MCM) for inhalational anthrax; Prepositioning of anthrax countermeasures; Time from release to dispensing
Distribution curve of incubation period, 6, 46
Distributive justice, 12, 165, 166, 170, 209-210
Dose effects in anthrax exposure, 51-52
Dosing concerns with predispensed antibiotics, 135
Doxycycline
adverse event risk, 131
allergic reactions, 132
anthrax post-exposure prophylaxis, 5, 42
concerns about antibiotic-resistant anthrax, 43-44, 45
emergency use authorization, 86
shelf life, 88
storage requirements, 114
Drills and exercises
data from, 10-11, 25, 162-163
head-of-household dispensing model, 75-77
push strategy, 78
recommendations for, 11, 164, 212
See also Postal model of distribution, pilot program; St. Louis, Missouri, pilot study
E
Emergency use authorization, 72, 86-87, 114
approval process, 79n, 86
definition, 28b
MedKit, 29b, 87, 119, 139, 142, 144t, 195-196
for Postal Model pilot program, 79, 87, 139
Environmental Protection Agency, 165-166
Ethical principles and issues, 11-12, 18b, 154b, 164-170, 198, 203, 209-210, 211
Ethnic/racial groups, 34, 158, 166
Expiration of medications, 85
implications for predispensing strategies, 88, 138
state-owned stockpiles, 102
workplace caching and, 114-115, 116
See also Shelf Life Extension Program
F
Faith-based organizations, 118
False alarms, 16
Federal Food, Drug, and Cosmetic Act, 86
Federal government
mission-essential personnel, 33
need for national guidance on public-private coordination, 109-111, 111b
as provider of threat information, 155-156
recommendations for, 2, 18b, 36, 164, 212
See also specific agency or department
First-order model, 175-180, 237-240
First responders
anthrax vaccination for, 32
in current distribution and dispensing system, 81
definition, 28b, 33-34
ethical obligations of communities to, 166
MedKits for, 139
need for special consideration of, 197
predispensed MCM for, 139-142, 198-199
prepositioning strategies for, 198
recommendations for prepositioning strategies, 16, 203, 211
risk of inappropriate use of predispensed antibiotics, 141
Flexibility of distribution and dispensing systems
concerns with predispensing strategies, 134-136, 198
to respond to drug-resistant anthrax, 45, 46, 136, 141
Food and Drug Administration emergency use authorization, 28b, 72, 79n, 86-87, 114
MedKit approval, 17, 119, 139, 141-142, 144t, 195-197, 199, 203
prescription laws, 86
recommendations for, 17, 203
shelf life extensions, 88
Forum on Medical and Public Health Preparedness for Catastrophic Events, 83
Forward-deployed MCM advantages, 95t
appropriateness and consequences of, 15t, 199-202, 200t
by commercial entities, 102-103
definition, 7, 8f, 29b, 93
at Department of Defense facilities, 101
determinants of effectiveness, 13
dispensing capacity, inventory levels and, 102
examples, 95t
impact on response time, 99
infrastructure needs, 95t
key features, 94, 95t
organizational entities needed for, 95t
potential health risks, 172
recommendations for local jurisdictions, 14-16, 18b, 203, 211
state control of, 73, 101-102
by Strategic National Stockpile, 99-101
at Veterans Administration hospitals, 101
Framework for decision making assessment of anthrax attack risk, 10b, 154-157
assessment of attack detection capabilities, 10b, 154b, 157
assessment of current dispensing capabilities, 10b, 154b, 158-163
cost-benefit modeling, 174-186
evaluation of likely economic costs, 10b, 154b, 173
evaluation of potential health benefits, 10b, 154b, 172-173
evaluation of potential prepositioning strategies, 10b, 154b
findings from cost-benefit modeling, 186-202
incorporation of ethical principles and community values, 10b, 154b, 164-170
key elements, 9, 10b, 153, 154b
need for, 108-109
purpose, 2, 9, 35-36, 153
recommendations for research to support, 19, 212-215
Fukushima, Japan nuclear accident, 120, 125-126, 128-129
G
Gastrointestinal anthrax, 41
Georgia, 77
Good manufacturing practice for pharmaceuticals, 86
H
H1N1 influenza pandemic, 3, 25, 71, 103, 108, 113, 163
Hamilton, New Jersey, postal facility, 56
Hazard Vulnerability Analysis, 156
Head-of-household dispensing model, 75-77, 82, 138
Health benefits and economic costs of prepositioning
evaluation in decision-aiding framework, 10b, 154b, 171
findings from cost-benefit modeling, 191-199
modeling methodology, 174-186, 237-240
recommendations for evaluation of, 13, 171, 202-203, 210-211
Health care providers
in closed workplace PODs, 114, 115-116
MCM caching in nonhospital health care facilities, 106
rationale for MCM caching in health care settings, 103, 104
recommendations for prepositioning strategies, 16, 203, 211
High-risk jurisdictions
determinants of risk, 155
forward deployment of MCM to, 99, 101
recommendations for assessment of capabilities, 11, 164, 212
value of prepositioning strategies in, 14, 197, 202
Home storage of antibiotics
in continuum of prepositioning strategies, 7
cost-benefit modeling of prepositioning strategies, 175, 181
cost comparison of prepositioning strategies, 195
creation of multi-drug-resistant anthrax and, 6, 45-46, 132-133
expiration of medications, 88
initial costs, 193
maintenance costs, 193-194
recommendations, 2
responsibilities of local jurisdictions, 138-139
storage and disposal issues, 133-134
See also Predispensed MCM
Hospital Preparedness Program, 104-105, 156
Hospitals and acute care facilities cost-benefit modeling of prepositioning strategies, 175, 181
cost comparison of prepositioning strategies, 195
costs of MCM inventory maintenance, 193-194
costs to dispense MCM from, 194-195
initial costs to stock MCM, 193
MCM caching in, 26, 103-105
as PODs, 104
potential effectiveness of closed PODs, 188-191
I
Inappropriate use
estimated prevalence, 128-130
form of predispensing and, 130
medication use instructions and, 137
risk among first responders and critical infrastructure personnel, 141
risk in predispensed MCM, 2, 16, 121, 128, 172-173
risk of antibiotic resistance in, 132-133
Incubation period of anthrax animal studies, 54-55, 61
cutaneous disease, 60
data sources, 6, 7, 34-35, 46-47, 61
distribution curve, 6, 46
dose effects, 51-52
historical evidence, 47-52, 61-62
implications for distribution and dispensing strategies, 6-7, 46, 55-57, 61
minimum, 46, 61
theoretical modeling, 52, 53-54b Insurance coverage, MedKit, 196
Investigational Device Exemption, 72
Investigational New Drug, 72, 121
Israel, 120
J
Joint Commission, 104
L
Legal issues
emergency use authorizations, 86-87
liability protection in emergencies, 86, 87, 109, 114, 116-117
in predispensing strategies, 139
prescription laws, 86
preservation of civil rights in emergency responding, 166-167
for private sector closed PODs, 115-117
scope of, 85
workplace caching, 114
Levofloxacin, 5, 42
M
Material Threat Determination, 5, 43, 44b, 155
MCM. See Medical countermeasures for inhalational anthrax
Meals on Wheels, 117
Medical countermeasures (MCM) for inhalational anthrax
antitoxin administration, 33
categories of strategies for, 7. See also specific strategy
current plans, 1, 3, 24-25, 69-71, 88-89
definition of MCM, 28b
generalizability of findings from research on, 30-32
private sector role, 3, 9, 107
public engagement in planning for, 12, 167-168, 170, 209-210
schematic of strategies for, 31f
vaccination, 32
See also Distribution and dispensing system; Predispensed MCM; Prepositioning of anthrax countermeasures
Medical/nonmedical points of dispensing, 75
MedKit
antibiotic supply in, 137
cost, 193
definition, 8f, 29b
disposal options, 193-194
emergency use authorization, 29b, 119, 139, 144t, 195-196
expiration of medications, 88
FDA-approved, 8f, 17, 29, 119, 139, 141-142, 144t, 195-197, 199, 203-204, 212
instructions for use, 137
legal issues, 139
over-the-counter, 119-120
pharmaceutical development costs, 196-197
pilot studies, 79, 121-124, 129-130
recommendations, 17, 18b, 203204, 212
replacement costs, 193
risk of inappropriate use of contents, 129-130
storage and disposal issues, 133, 134
Memoranda of understanding/ agreement, 110, 113-114
Metropolitan statistical areas, 73
Minneapolis-St. Paul, Minnesota, 79-80, 120, 123-124, 129-130, 139, 141
Minnesota. See Minneapolis-St. Paul, Minnesota
Mission-essential personnel, 33
Missouri. See St. Louis, Missouri, pilot study
Model Pharmacy Act, 114n
N
National Alliance of State Pharmacy Association, 108
National Association of Chain Drug Stores, 108
National Association of County and City Health Officials, 108
National Bioterrorism Hospital Preparedness Program, 104n
National Community Pharmacists Association, 108
National Voluntary Organizations Active in Disaster, 117
Natural disasters, 25
Nerve agent antidote program, 100-101, 100b, 120
New Tools for Assessing State and Local Capabilities for Countermeasure Delivery, 161
New York state, 101-102
O
Oseltamivir, 196
P
Packaging
FDA-approved MedKit, 196
predispensed MCM, 17, 130
Pandemic and All-Hazards Preparedness Act, 104N
Penicillin G, 5, 42, 131
Personal stockpile
definition, 8f, 29b
indications for, 198
individual purchase of, 198
legality, 139
misuse concerns, 130, 137, 144t
recommendations, 16, 203
storage and disposal issues, 134
See also Home storage of antibiotics; MedKit
Pharmaceutical Research and Manufacturers of America, 108
Pharmacies
in coordinated response to H1N1 influenza pandemic, 108
MCM caching in, 106-107
need for framework for collaboration with government in response to anthrax attack, 108-109
as POD sites, 74-75, 107
private sector role in forward deployment of MCM, 102-103
Philadelphia drill, 75, 82
POD. See Points of dispensing
Points of dispensing (PODs) benefits of prepositioning, 14
closed, 71, 75, 77, 109, 112-113
costs to dispense MCM, 194-195
current concerns about plans and capabilities, 82-83, 85
current distribution and dispensing plans, 1, 3, 71, 73-74, 88-89
definition, 14, 28-29b
determinants of effectiveness, 74
drive-through, 74
head-of-household model, 75-77
hospitals and acute care facilities as, 104
medical/nonmedical, 75
nonhospital health care facilities as, 106
open, 73-74
potential effectiveness of prepositioning strategies, 188-191
private sector agreements with jurisdictions, 110
private sector locations, 109
processing time, 85
rationale for forward deployment of MCM, 99
retail pharmacies as, 107
security concerns, 82
sites for, 74-75, 85, 101
staffing, 74, 75, 83
time needed to make ready, 99
transportation considerations in selection of, 85
See also Workplace caches
Postal model of distribution, 3, 74
advantages, 79
in current distribution and dispensing plans, 71
Executive Order on, 26, 80
follow-up monitoring of kits, 88
goals, 79
legal liability protections in, 87
obstacles to implementation, 80-81
pilot program, 26, 43-44, 79-80, 88, 120, 123-124, 129-130, 135, 139, 141
predispensed MCM for families of postal workers, 140
rationale, 78-79
security issues in, 80-81
Postal system, anthrax attacks of 2001, 23, 47, 56-57, 84
Potassium iodide, predispensing of, 120, 124-127, 124b
Predispensed MCM
adherence issues, 84, 138
advantages, 97-98t
appropriateness and consequences of, 15t, 199-202, 200t
communications challenges, 136-138
comparison of different forms of, 143, 144t
in continuum of prepositioning strategies, 7, 119
costs, 197
definition, 8f, 94, 119
determinants of risk associated with, 127
dosing concerns, 135
evaluation of risk associated with, 127
expiration of medications, 138
flexibility concerns, 134-136
forms of, 7, 119-120
to general public, 14, 16, 120, 126, 127- 128, 130, 134, 136
historical experience, 120-127
inappropriate use risk, 16, 17, 121, 128- 130, 172-173
infrastructure needs, 9 7-9 81, 138-139
key features, 94, 97-98t
legal issues, 139
for patients with special medical needs, 142-143
multidrug model, 135
organizational entities needed for, 97-98t
public understanding of proper use of, 137
recommendations for, 14-16, 203, 211
risk of adverse drug events, 130-132
risk of antibiotic resistance from misuse of, 132-133
risk of unintended ingestion, 133
scope of concerns about, 127-128
screening for contraindications to use, 135-136
special challenges in, 119
special packaging for, 17, 130
state and local responsibilities, 138-139
storage, 114, 133
to targeted populations, 14-16, 16, 17, 33-34, 139-143, 197, 198- 199, 203
See also Home storage of antibiotics
Pregnancy, 135
PREP Act Declaration, 87
Prepositioning of anthrax countermeasures
annual maintenance costs, 193-194
categories of strategies for, 7, 36, 93-94, 95-98t, 170-171. See also specific strategy
comparison of appropriateness and consequences of strategies, 15t, 199- 202, 200t
as component of national security strategy, 3, 26, 215
concerns about negative consequences, 2, 3, 14, 93
continuum of strategies, 7, 27, 29b
cost components, 191-192
cost evaluation, 13, 173
cost to dispense, 194-195
definition, 1, 3, 29b
ethical issues, 168-170
expiration of medications, 88
findings from cost-benefit modeling, 188-202
health risks, 2, 172-173
implications of multi-drug-resistant agents, 5-6, 43-46
initial stocking costs, 193
issues of concern, 262
legal issues, 86-87
need for national guidance on public-private coordination, 109-111
potential effectiveness of strategies, 188-191
potential limitations to effectiveness of, 2, 14, 172
public behavior as determinant of effectiveness of, 137-138, 188
rationale, 1, 3, 13-14, 26, 93, 171, 172
recommendations for evaluation of strategies for, 12-13, 18b, 202-203, 210-211
recommendations for integration of ethical principles and public engagement in, 11-12, 18b, 170, 209-210
recommendations for national guidance on public-private coordination, 9, 18b, 112, 211
recommendations for research to inform decision making on, 18b, 19, 212-215
recommendations from cost-benefit modeling, 202-204
resource demands, 2, 191-193, 197
risk-related information for, 156-157
strategies for, definition and scope of, 29b, 171
study goals, 4, 21-22
study process, 4-5, 22-23, 27
See also Framework for decision making; Recommendations
Presidential Executive Orders, 26, 33, 80
Private sector
arrangements with local jurisdictions for distribution and dispensing, 110
collaboration in response to H1N1 influenza pandemic, 108
in forward deployment of MCM, 102-103
legal issues in MCM distribution and dispensing, 87, 115-117
in MCM caching, 107
in MCM development and delivery, 3, 26, 77, 107, 108-109
need for framework for collaboration with government in response to anthrax attack, 108- 109
need for national guidance on public-private coordination, 109- 111, 111b
obstacles to participation in distribution and dispensing system, 9, 107, 109-110, 112
obstacles to successful collaboration with government, 77, 117
potential POD sites, 74, 77, 109
recommendations for national guidance on public-private coordination, 9, 18b, 112, 211
state push strategy experiment, 78
understandings and agreements with jurisdictions, 110, 117
See also Pharmacies; Workplace caches
Public, defined, 29b, 33
Public health
challenges in responding to aerosolized anthrax attack, 1, 2, 21
ethical framework for MCM planning, 11-12, 164-170, 209-210
recommendations for local jurisdictions to improve dispensing capabilities, 14-16, 18b, 203, 211
Public Health Emergency Preparedness Cooperative Agreement, 105, 161,162-163
Public Health Law Network, 115
Public Health Preparedness Capabilities, 159-160
Public Health Preparedness Capabilities, 25
Public knowledge and understanding adherence to prophylactic antibiotic regimen, 84
concerns about antibiotic-resistant anthrax, 44b
of dispensing system, 85, 104
dosing concerns with predispensed antibiotics, 135
participation in MCM planning, 12 165, 167-168, 170, 209-210
for predispensing strategies, 136-137
role of clinicians and first responders in MCM system, 81
strategic planning for MCM dispensing, 83-84
use of MCM in response to perceived threat, 125-127, 128-129, 137
Public Readiness and Emergency Preparedness Act, 85, 86, 87, 110, 114,116-117
Pull strategies, 73-74
Push Packages, 43, 72, 88, 159
Push strategies
advantages, 78
definition, 73-74, 78
disadvantages, 78
recommendations, 14, 203
state experiments, 78
See also Points of dispensing (PODs), closed; Postal model of distribution
Q
Q-fever, 52, 54b
Quarantines, 168
R
RAND-CDC Performance Metrics Project, 161
Receiving, staging and storage centers in current distribution and dispensing system, 71, 72
rationale for forward deployment of MCM, 99
time needed to make ready for distribution, 99
Reciprocal obligations, 12, 165, 166, 170, 209-210
Recommendations
against development of FDA-approved MedKit, 17, 18b, 212
for assessment of distribution and dispensing systems, 11, 164, 212
for evaluation and development of prepositioning strategies, 12-13, 18b, 202-203, 210-211
for federal government, 9, 11, 17, 18b, 19, 112, 164, 204, 211, 212, 214, 215
for integration of ethical principles in prepositioning strategies, 11-12, 18b, 170, 209-210
for large-scale exercises, 11, 164, 212
for national guidance on public- private coordination, 9, 18b, 112, 211
for public engagement in MCM planning, 12, 18b, 170, 209-210
for research to inform MCM decision making, 18b, 19, 212- 215, 213-214t, 215b
Red Cross, 117
Regional distribution centers, 71
Research needs, to inform decision making about prepositioning strategies, 18b, 19, 212-215, 213- 214t, 215b
Risk of anthrax attack
assessment of, for decision-aiding framework, 154-157
components of risk, 155
Department of Homeland Security assessments, 156
high-risk jurisdictions, 11, 14, 99, 101
implications for prepositioning strategies, 156-157, 186
recommendations for assessment of, 12, 18b, 202-203, 210-211
S
Schools, cached MCM in, 118-119
Security issues closed workplace PODs, 114
concerns about current dispensing system, 82
in postal model of distribution, 80-81
Shelf life. See Expiration of medications
Shelf Life Extension Program, 85, 88, 99, 101, 102
Skilled nursing facilities, 105-106 SNS: Supply Chain Dashboard, 108
Socioeconomic status, access to MCM and, 34, 117-118, 158, 166, 169
Special need patients, 142-143
St. Louis, Missouri, pilot study, 120, 121-123, 129-130, 133, 137, 141
Staffing
clinicians and first responders in distribution and dispensing system, 81
concerns about current dispensing system, 83
points of dispensing, 74, 75, 83
role of medical professionals in closed workplace PODs, 114, 115-116
Stafford Act, 110
State, local, and tribal jurisdictions arrangements for private sector collaboration in distribution and dispensing, 110
assessment of distribution and dispensing capabilities, 10-11, 35, 82
current MCM plans for anthrax, 3, 73-74, 88-89
decision making on prepositioning strategies. See Framework for decision making
legal issues for private sector PODs, 115-116
local dispensing capability as rate-limiting factor in attack response, 187-188
recommendations for, in development of national guidance for public-private coordination, 9, 112, 211
recommendations for assessment of MCM planning and implementation, 11, 164, 212
recommendations for evaluation of prepositioning strategies, 12-13, 18b, 202-203, 210-211
recommendations for improving dispensing capabilities, 14-16, 18b, 203, 211
recommendations for integration of ethical principles in MCM planning, 11-12, 18b, 170, 209-210
regional distribution centers, 71
responsibilities in predispensing strategies, 138-139
state control of forward-deployed MCM, 101-102
variations among, effectiveness of prepositioning and, 14, 35, 153, 154b, 197
State Homeland Security Program, 156
State Mitigation Plan, 156
Stewardship, 12, 165, 166, 170, 209-210
Storage of medications, 114, 133
Strategic National Stockpile anthrax antitoxin stockpile, 33
assessing time to delivery from, 159
CHEMPACK Program, 100-101, 100b
contents, 43, 45, 71-72
in current MCM plans, 1, 3, 7, 24, 69-72, 88-89
definition, 30b, 71
forward deployment of MCM by, 99-101
process for withdrawals from, 72
recent deployments, 71
recommendations for assessment of capabilities, 11, 164, 212
response to antibiotic-resistant anthrax attack, 45
stock rotation and replacement program, 88
Technical Assistance Review, 25, 160
warehouse locations, 99
Sverdlovsk incident, 7, 23, 34-35, 43, 49-52, 53b, 54b, 61
T
Technical Assistance Review, 25, 160
Threat and Hazard Identification and Risk Assessment, 156
Tier 1 cities, 99, 156, 159
Tier 2 cities, 156
Time from release to dispensing assessment of detection capabilities, 157
benefits of prepositioning, 3, 13-14, 93, 172, 202
data sources for MCM planning, 35, 127
detection technology and, 35, 58-61, 85
establishment of POD sites, 99
forward deployment of MCM and, 99
impact of time to detection, 57, 61, 62
importance of timely decision making, 13-14, 61, 187, 188
modeling of prepositioning strategies, 176-181, 187, 237-240
POD processing time, 85
potential effectiveness of prepositioning strategies in reducing, 188-191
predispensed MCM risk assessment, 127
stages, 57
Strategic National Stockpile delivery time, 159
Transparency
importance of, 165, 166
recommendations for, 12, 170, 209-210
Transportation issues, 85, 158
Tularemia, 52, 54b
U
UPS, 78
Urban Areas Security Initiative, 99, 156
V
Vaccine, anthrax, 26, 32, 42
Vendor-managed inventory, 72, 159
Veterans Administration hospitals, 101
Virginia, 78, 103
Vulnerability of jurisdictions, assessment of, 155, 156
Vulnerable and at-risk populations assessment of distribution and dispensing system capability, 158
ethical obligations in prepositioning planning, 166, 169-170
predispensed MCM for, 139-140, 198-199
role of community organizations in MCM dispensing, 117-118
types of, 34
W
Washington State exercise, 75-77
Workplace caches, 1, 2, 3, 22, 29, 73, 74, 107
advantages, 112-113, 198
antiviral stockpiles, 113
cost-benefit modeling of prepositioning strategies, 175, 181
cost comparison of prepositioning strategies, 195
costs to dispense MCM, 195
current implementation, 113
for first responders and critical infrastructure personnel, 140
initial stocking costs, 193
legal issues, 115-117
logistical arrangements, 113-115
maintenance costs, 193-194
medication shelf life issues, 114-115, 116
potential effectiveness, 188-191
public seizure of, 117
role of medical professionals in operations of, 114, 115-116
security concerns, 114
storage space, 114
supply sources, 112