Welcome, everybody, to the ACPM's webinar series on public health emergency preparedness and response that we've developed to support preventive medicine residents. This series of webinars was developed to help augment the training that they already receive within their residency programs. Next slide, please, Dr. Brett. Thank you. Just one quick few moments of housekeeping before we move forward to the next slide. Please attend the webinars and feel free to ask questions to Dr. Brett. The questions will be answered towards the end. Towards the end, during the Q&A session, I will also post a survey on the chat. Please complete the survey and provide us with your feedback and help us improve. This is a pilot series. We encourage you to continue discussing this topic and other topics of the webinars that have already been completed through our new online discussion forum for members called ACPM Pulse that many of you may already be familiar with. And of course, this webinar is being recorded, and ACPM will continue to share instructions as to how you can access this recording and previous recordings. Next slide, please. Okay. It is my distinct pleasure today to introduce our faculty, Dr. Catherine Brett. Dr. Catherine Brett is a board-certified preventive medicine and women's health expert with over 20 years of experience in the medical field. A skilled clinician and surgeon, she has routinely received patient satisfaction and safety awards during her clinical practice. As the clinical medical director, health informatics for Mississippi Division of Medicaid, Dr. Brett coordinates clinical outcomes tracking and reporting, designs and implements research studies for population health, evaluates internal initiatives and external program performance measures, and integrates evidence-based health intervention into quality improvement activities for the state. Adept at effective communication with a collaborative leadership style, she educates and engages healthcare professionals, community partners, and external stakeholders in meaningful dialogue to further the Division of Medicaid's comprehensive quality strategy. Dr. Brett is one of our newer fellows at the college and very actively involved in mentoring residents and early career physicians. Once again, it is a privilege to have Dr. Brett provide the lecture for the next topic, Stockpiles and Limitations. With that, Dr. Brett, I turn it over to you. All right. Thank you so much and good evening. It's wonderful to be here to speak with you guys about resources and their limitations available to public health providers during an emergency response. Specifically, we'll be discussing the strategic national stockpile, and that can provide critical medical assets to the site of a national emergency when local resources have been exhausted. I have nothing to disclose for this discussion, except that I'm really excited to be here with you guys tonight, so. Helene was a Category 4 hurricane that made landfall on Florida's Gulf Coast back on September 26th. It then moved through the southern U.S., killing more than 200 people across six states and causing between 30 and 48 billion, that's billion with a B, in property damage. In the wake of this destruction, production was halted at a Baxter International Manufacturing Facility in North Carolina. Baxter is the largest manufacturer of IV fluids and peritoneal dialysis solution in the U.S. This closure caused massive supply interruptions. Hospitals and government agencies were left scrambling to cope with these shortages. Not only were supplies diminished, but the infrastructure in the areas that needed it most was severely depleted. Mule trains were having to traverse the Appalachian Mountains to get needed resources to communities where bridges and entire highway systems were washed away. In a statement in October, Baxter reported that until it could fully ramp up its domestic production, the company was working with the FDA and ASPR to begin importing supplies from several of its international facilities. FDA conducted scientific and regulatory assessments for the temporary importation of 23 different IV and peritoneal fluid products from five Baxter facilities around the world. The FDA also loosened regulations on IV fluid compounding so that hospitals could make their own IVs until replacements could be delivered. As a preventive medicine physician in the Southern U.S., weather-related public health emergencies like hurricanes and the resulting tornadoes, storm surges, and flooding are always top of mind, but other public health emergencies have popped up in my time as clinical medical director for Medicaid. In the early days of COVID, I was in charge of deciding when regional offices needed to close, how long, and what was the protocol for staff to return to work, how do we get PPE and testing equipment to our regional offices, reviewing applications for out-of-state providers to supply laboratory services and durable medical equipment for our struggling hospitals, and opening administrative codes to cover telehealth services. During the last two years, Jackson's experienced two different water crises, a baby formula shortage, and we're currently in a congenital syphilis crisis during a national drug shortage of the only FDA-approved antibiotic to treat syphilis in pregnancy available in the U.S. So whether you plan to work at a public health department after residency or not, understanding what resources are available and how to access them will be vital in your career when you may be the only public health-trained clinician in the room and everyone is looking to you for answers. Today, we'll be discussing the strategic national stockpile, its supply chain, and associated limitations, but what I want you to learn from our discussion is what does this mean to you, a preventive medicine physician. At the end of our webinar today, you'll be able to identify what your role may be in responding to a PHE. Think through your role, your environment. How equipped would you be in an emergency? What resources can you think of that you have plenty and could share with the community versus what assistance would you need to ask for? Where would you go? Who would you ask for these resources? Understanding how local, state, and federal assistance all collaborate and work together for community protection and how the SNS fits into that picture. So first, let's talk about how the SNS is organized. The Administration for Strategic Preparedness and Response, or ASPR, serves as the lead federal health agency responsible for helping communities prepare for, respond to, and recover from disasters and emergencies. ASPR accomplishes this in several ways, including developing, stockpiling, and distributing response tools against multiple threats. They send clinical response teams to places in time of crisis, and they ensure our healthcare and public health partners have the knowledge and tools they need to navigate healthcare security threats. To ensure ASPR is meeting the nation's medical and public health needs before, during, and after a disaster or a public health emergency, they focus on four key areas, preparedness, response, partnership, and workforce readiness. ASPR must be prepared to execute public health and medical missions in response to a wide variety of threats and hazards. This includes using predictive modeling to decide what future threats and hazards may be. As the federal medical and public health lead, ASPR works to equip the healthcare delivery system for response and recovery and provide surge and behavioral health support and public health supplies needed for patient care during disasters. A successful PHE or disaster response is reliant on a strong partnership with key stakeholders. And finally, ASPR workforce must be agile and responsive. At a moment's notice, they could be deployed and need to be able to hit the ground running. ASPR falls under the Department of Health and Human Services, and the SNS is one of seven centers under ASPR structure. The deputy assistant secretary and director provide leadership and direction for SNS. They set the strategic priorities and provide executive oversight for all activities to support the SNS and stakeholder readiness. There's also a deputy director who assists the director in managing the day-to-day operations of the SNS, act as a second level supervisor overall, but then also provides direct supervision and oversight to the division of communications. Science plays a key role in managing the SNS formulary and is often the touch point for scientific and clinical collaboration with other agencies, such as the FDA, the CDC, and NIH. Management of the business operations is ASPR's budget, business operations, and quality control requirements for the SNS. Logistics is responsible for inventory management, warehouse operations, and transportation of SNS medical countermeasures. National Readiness and Response runs the SNS operations center and includes subject matter experts for developing the countermeasure plans, training, and exercises. The Supply Chain Alliance and Development actively engages with government and non-governmental partners around supply chain forecasting, shortages, and security through the Supply Chain Control Tower. State, local, tribal, and territorial preparedness is responsible for coordination of technical assistance and serves as a key point of contact for the SLTT. Whether it's a disease outbreak or a terrorist attack, there are medical countermeasure plans in place throughout the nation to protect our communities. The CDC, along with ASPR, work directly with state and local officials to prepare them to respond to public health threats. The CDC provides guidance on how communities can protect people, safely reduce food and water supply, and monitor for contamination following a chemical, biological, radiologic, nuclear, and explosive, or CBRN, incident. In the face of a public health threat, SLTT health officials and public health agencies are expected to take the lead when public health emergencies occur. However, they may need to receive additional support when local resources are depleted. The purpose of the SNS is to supplement and to resupply state and local public health agencies in the event of emergency. The SNS official mission is to prepare and support partners and provide the right material at the right time to secure the nation's health. Some facts about the SNS. It is the government's largest repository of emergency medical countermeasures, or MCM. It was established in 1999 as the National Pharmaceutical Stockpile, and it now has approximately $13.5 billion inventory of MCMs to respond to chemical, biologic, radiologic, and nuclear threats, burn or blast events, emerging infectious diseases, pandemics, and natural disasters. They have assets for responding to multiple emergency situations. It stores medicines such as antibiotics and antivirals, and other life-saving medications, as well as medical supplies like IV fluid administration supplies, airway maintenance supplies, and other medical and surgical items. The SNS warehouses are professionally managed by commercial third-party logistic providers, and we'll review why this adds an element of fresco into the equation later on. As this timeline shows, the SNS mission requirements and capabilities have grown from 1999 to today through new threats and responses. In 1999, the U.S. Congress tasked the CDC with developing a stockpile of medical supplies for rapid response in the event of a bioterrorist event, such as anthrax or tularemia. After September 11th terrorist attacks, administration of the stockpile was transferred to the Department of Homeland Security before finally finding a home under HHS's Assistant Secretary for Preparedness and Response. During the H1N1 outbreak of 2009, the SNS deployed over 12.5 million antiviral regimens and nearly 20 million pieces of PPE. During the recovery after Hurricane Katrina, the SNS provided 3,500 beds, 250,000 vaccines against communicable diseases, and 30,000 vials of insulin to Louisiana and Mississippi. According to a report from the Government Accountability Office, the SNS has received annual appropriations from Congress ranging from $522 million in federal fiscal year 2013 to $845 million in 2022. The United States also maintains stockpiles for emergency purposes other than healthcare, such as the Strategic Petroleum Reserve, the Northeast Home Heating Oil Reserve, the National Defense Stockpile, and the National Plant Germplasm System. The SNS was designed to ensure the nation's readiness against potential threats of bioterrorism, as we said, from botulism, smallpox, anthrax. Additional threats to the nation's public health required strengthening of our readiness to respond to these public health events. The SNS has evolved over time in inventory and acquired additional resources, which allows ASPR to continue supporting natural and man-made disasters, outbreaks, and deployment of small and large-scale unique medical countermeasures. Specific specifications of the SNS are not fully known to the public due to national security implications. However, we have some general idea of what is included. So when a public health emergency occurs, federal assistance can be requested. As the scope of the request varies according to need, local emergency management teams work together to identify which assets to request. Presidential Policy Directive 8 is aimed at strengthening the security and resilience of the United States through systematic preparation for the threats that pose the greatest risk to the security of the nation. Communities can address the risks these threats and hazards pose by working together using a systematic approach that builds on proven preparedness activities. PPD-8 describes a collaborative environment and living system whose components will be routinely evaluated and updated to ensure their continued effectiveness in meeting the national preparedness goal. At least that's the intention, right? We'll talk about this later in the limitations section. So what potential threats could your community face? The National Preparedness Report identifies three types of threats for local and global communities. Natural hazards, technical and accidental hazards, and adversarial human-caused hazards. Natural hazards include weather events, animal disease outbreaks, and human pandemic outbreaks. Technical and accidental hazards include dam failures or chemical substance spills. Adversarial human-caused hazards include explosions or food contamination by terrorism attacks. The S&S formulary includes medical countermeasures and supplies for dealing with these threats, including Category A threat agents, including smallpox, anthrax, botulism, viral hemorrhagic fevers, plague, and tularemia, as well as certain Category B agents, typhus fever, and glanders. It also prioritizes medical countermeasures used against chemical nerve agents, radiation and nuclear events, including burn and blast emergencies, pandemic influenza, emerging infections, and natural disasters. The S&S stores medicine, such as antibiotics, antivirals, antitoxins, chemical antidotes, and other life-support medications, as well as medical supplies, like IV administrative supplies, airway maintenance supplies, and many other medical and surgical items. According to ASPR, the S&S has large quantities of medicine and medical supplies to protect the American public if there's a public health emergency, severe enough to cause local supplies to run out. Once federal and local authorities agree that the S&S is needed, medicines will be delivered to any state in the U.S. in time for them to be effective. Each state has plans to receive and distribute the S&S. This table shows an overview of some of the threats, the prophylactic countermeasures, and the treatment countermeasures held in the S&S by category for each of those threats. I'm not going to go through these all because you all will get these slides later on, but you can see this is just a top-level overview of all the different categories that we house in the S&S. There were changes to the S&S inventory due to the COVID-19 pandemic. The S&S formulary now contains additional finished pharmaceutical products, such as sedatives for use with ventilators. In response to recommendations from HHS, ASPR also added testing supplies to the S&S inventory in late 2020, including nasal swabs and transfer media. Prior to the COVID-19 pandemic, the S&S did not hold these kinds of medical countermeasures. The U.S. pharmaceutical and medical material supply chain is really broad, but it's very shallow. There's less than a 30-day supply for most pharmaceuticals and PPE. Stockpiling ensures emergency access to medical countermeasures when there's times of need. MCMs are normally held for one or more reasons. They either have no commercial market to ensure production, like for a smallpox vaccine, a product is available but not in sufficient quantities, or the commercial supply chain can't dispense product in adequate amounts or within a given timeframe. An example of that might be ciprofloxacin or doxycycline, which can be obtained at pharmacies, but not in the quantities needed for a mass prophylactics campaign. S&S management includes overseeing the shelf life of medicines to ensure the stock is rotated and keep within FDA potency shelf life limits, conducting routine quality assurance on all products, performing annual inventory of all products, inspecting environmental conditions, security, and package maintenance, ensuring S&S holdings are based on the latest scientific data and threat level, and ensuring the ability to transport items during a public health emergency. So how does S&S determine what medical countermeasures will be added to the formulary and under what conditions? Well, S&S has a budget for medical countermeasures, but can't get everything that's available on the market at one time. ASPR's website reports that they don't have an unlimited budget, although I would think 845 million is a sizable amount of money, but that's what it says, and that they don't want to create unanticipated issues in the supply chain with high volume procurements. So federal government partners play a role in identifying requirements and prioritizing acquisitions. The Department of Homeland Security determines what the threats are, and HHS determines what the population breakdown is, with considerations for vulnerability to certain threats and the demographic ranges for certain medications. Finally, the Public Health Emergency Medical Countermeasures Enterprise, we'll call it PHMSE, I'm not sure that's how they say it, but that's how I'm going to say it today, prioritizes MCMs for the threats identified by Homeland Security and makes the final recommendation for ASPR procurement. During an emergency, it's imperative that there's an understanding of what is urgently needed and what is available to address that MCM need. Partners work together to secure approval and supplemental funding for immediate needs in the response. Even after the PHE is over, continued funding may be needed to maintain the new inventory and provide storage, like procuring new vaccine storage fridges for the COVID vaccines after they commandeered all the Dippin' Dots freezers. There are three main strategies for deploying resources during a PHE response that the S&S uses. In the early days of a PHE, the exact conditions or supplies needed may be evolving or still being investigated. A broad range of supplies may be needed to stem the initial emergency surge. As more details emerge, then specific items or medical countermeasures can be deployed to target the exact needs of the community. Some assets are forward deployed, meaning they're set up ahead of the disaster to have resources on hand to deliver rapid support and immediate use. These include ChemPacks and 12-hour push packages. Assets to meet specific requirements include S&S-managed inventory, vendor-managed inventory, and federal medical stations. S&S provides technical assistance for state, local, tribal, and territorial partners to plan for all of these situations. S&S's inventory includes a large quantity of assets packaged to meet specific requirements, but they're also able to leverage ASPR's purchasing power in certain situations to directly order items that are not held in inventory. A 12-hour push package is a cache of pharmaceuticals and medical supplies designed that provide rapid delivery of a broad spectrum of assets in the early hours of an event when very little is known about what specific agent or threat is involved. This cache is packed in cargo containers that can be delivered anywhere in the United States within 12 hours of the federal decision to deploy. The 12-hour push packages are strategically located at secure warehouses throughout the United States, ready for immediate deployment. Improved ability to identify causative agents and laboratory technology has reduced the time needed for confirmatory results. And remember, deployment is after the states have run through the resources and requested aid. The specific inventory needed may be known by the time the request is authorized, so SNS's need to deploy such broad-spectrum support material has decreased as the program evolves. For most situations, a response within 12 hours is adequate. However, a chemical or nerve attack requires a more rapid response. That's why in 2004, the CDC established the CHEMPAT project, which ensures that chemical and nerve agent antidotes can be administered as quickly as possible after the attack. The antidotes are pre-positioned within the local jurisdictions with designated local personnel such as public health department, a hospital, or emergency management, providing a secured facility for and maintaining custody of the antidotes. Though they're housed at the local level, the CDC maintains ownership of the CHEMPACs and ensures they're stored properly within the facility. Containers are divided into three types. There's hospital containers, which provide about 1,000 treatments, EMS containers, which provide 454 treatments, and weapons of mass destruction containers for specialized EMS vehicles, which provide around 908 treatments. And here is a map showing all of the CHEMPAC caches in general locations. Again, we don't want to tip off anybody where we're keeping our national security. But the CHEMPAC pilot program began with three volunteer jurisdictions. In March of 2008, the CHEMPAC program completed the fielding of containers in every state and large city in the US, including Alaska and Hawaii, which ensured about 90% of Americans are within one hour of a CHEMPAC container. The CHEMPAC program concluded its final stage of fielding known as the Islands Plan in May of 2012, which accomplished a major preparedness milestone by placing over 1,970 CHEMPAC containers in all 62 states, territories, and insulated areas supporting the Pacific Islands as well as the US Virgin Islands and Puerto Rico and the Caribbean. SNS owns, maintains, and monitors all containers for the 62 state, territorial, and island jurisdictions that receive funds from the CDC's Public Health Emergency Preparedness Cooperative Agreement. Voluntary participation in the program requires participating awardees meet the following criteria. They have to designate a lead agency and appoint a contact to work with SNS. They have to identify and maintain secure, climate-controlled storage sites that best support existing emergency response plans. They have to integrate the use of CHEMPAC assets into all hazard response plans, identify a Drug Enforcement Agency registrant to accept custody of the CHEMPAC material, and sign the Memorandum of Agreement to partner with SNS in the CHEMPAC program. Since detection and identification capabilities have improved significantly, we're more likely to know what specific SNS assets will meet a resource need at the state, local, tribal, and territorial level. We must behold those assets primarily in SNS-managed inventory. SNS partners with third-party logistic companies for warehouse operations. In the event that the stockpile doesn't have adequate inventory of a particular item, the SNS has the capability to purchase medical supplies that are not stocked or that are in high demand during a large-scale emergency. It is able, through the National Acquisition Center, to negotiate the rapid purchase of medical supplies, which allows for greater on-hand search capability for critical items. If those items are available, like in the Baxter facility closure example, what happens when there are no other supply chains to purchase from? So vendor-managed inventory, also known as VMI, may also be used in certain circumstances for the deployment of SNS's MCM. Federal medical stations are rapidly deployable caches containing beds, supplies, and medicines, which can quickly turn a pre-identified building into a temporary medical shelter during a national emergency. SLTT partners must provide a building of opportunity and wraparound services. Care can be provided for 50 to 200 displaced people for three days before resupply is necessary. The FMS offers health and medical search capability and capacity for short-term inpatient persons who have subacute medical, mental health, or other health care needs that cannot be accommodated or provided for in a general shelter. The FMS can be utilized as a 50 to 200-bed non-acute care, dealing with conditions that aren't life-threatening, as a hospital unit or alternative treatment center during a hospital surge or just a location to conduct triage. FMS is not accompanied by medical professionals, though, to staff the operation, so volunteers for staffing must be planned and coordinated prior to the event. The Emergency System for Advanced Registration of Volunteer Health Professionals, SRVHP, is a federal program created to support states and territories in establishing standardized volunteer registration programs for public health and medical emergencies. These databases are used to track contact information and verify credentials for unaffiliated doctors and nurses willing to volunteer during disasters, as well as members of local Medical Reserve Corps units across the country. Federal resources such as the Disaster Medical Assistant Teams and the VA Health System, those care providers might also be requested to augment staffing in a public health disaster. The S&S supplements critical product shortages, but will not cover every possible threat since the commercial supply chain has a primary role. Benefits of integrating S&S and commercial supply chain response planning and capabilities include reducing unplanned redundancy, potentially reduced stockpiling requirements for S&S and partners, strengthen commercial capacity and resilience, identify and mitigate risks. The S&S supplements critical product shortages, but will not cover every possible threat since is the primary role of the supply chain. HHS actually came to Mississippi to hold a congenital syphilis task force two months ago to assist with our congenital syphilis crisis. And I asked specifically about the S&S resources to help supplement bycellin shortages in our local community. HHS actually advised that they would rather Mississippi execute an emergency use authorization of imported foreign pilosellin as it was available for purchase through supply chain instead of utilizing S&S resources. The request for S&S assets is initiated by the local jurisdiction in response to a potential or actual problem and is a formal process. First, the public health department in coordination with local emergency management determines if and when local assets will be exhausted. Next, if local resources are projected to be overwhelmed, the jurisdiction can request S&S assets, but must justify this action. Many situations are going to justify a request when local resources are scarce, but some of these are overt occurrence of a seabird incident, medical emergency caused by natural disaster, indication from federal law enforcement of a likely attack, just for example. Medical crisis can also justify a request such as when results from a laboratory test or medical surveillance indicate a large number of people with a similar disease, symptoms or cause of death. A single cause of disease occurring in an uncommon group or an unexpected area or during a season when it's not typically seen. Simultaneous clusters of similar illness in different areas of the country or an unusual genetically engineered or antiquated strain of an agent. Once the request is made by the jurisdiction, the public health authority, through local emergency management, forwards the request to the state governor who will likely consult with the state's Department of Health and Department of Emergency Management and then officially request the S&S from the federal government. The Department of Homeland Security and HHS will review and approve the request. Finally, once approved, ASPR will then initiate the deployment process. Once the federal decision to deploy has been made, S&S assets will be delivered to their designated state, RSS site. Each state has at least two locations identified and approved by ASPR as RSS sites. These large warehouse facilities will be as close as possible to the affected area to deliver the assets as quickly as possible. When the assets are delivered to RSS, the state's Department of Health takes possession of the assets and arranges distribution to the local jurisdiction based on the medical countermeasure plans. This slide reviews ASPR's distribution model during the COVID-19 PAG. The green on the far left shows the traditional model where S&S delivers product to state public health warehouses and then the state public health is in charge of distributing to those local sites. As the pandemic evolved, enhanced S&S distribution models with additional strategies were shown to be effective. S&S deployed HCOR, which is HHS Coordinated Operations and Response Element, and pharmaceutical partners to leverage the commercial and dedicated fleet capabilities to distribute countermeasures such as PPE and testing supplies through the existing pharmaceutical distribution channels. For many countermeasures such as treatment and therapeutics, S&S made direct shipments from this S&S to the point of care, which lessened the coordination burden on SLT public health partners and resulted in faster and more efficient delivery to the point of need. During a medical countermeasure campaign, the goal is to reach as many people as possible and as little time as 48 hours in an effort to minimize the effect of the threat. This planning goal is based on the worst-case scenario for anthrax exposure of 100% of the population in 48 hours. Many POD plans, depending on the medication dispense, allow a head of household, a member of the family, or a representative of a small group to pick up the pills. The HOH must have completed forms or the information to complete the forms before they're allowed through the POD process to collect the medications. To help rapidly achieve this goal, a community may establish PODs, which operate within the national incident management systems and under local public health. Different type of PODs are necessary to meet the needs of various community populations in an efficient manner. In general, PODs are for non-symptomatic, potentially or actually exposed people. Symptomatic individuals should go to hospitals or other treatment facilities. An open POD is a dispensing site that's open to the general public to rapidly provide medical countermeasures to a large number of people. A closed POD is a dispensing site that's set up for a pre-identified population associated with a specific business or organization, for example, jails or prisons or a faith-based organization, and is not open to the general public. A drive-through POD is an open or closed POD that does not require individuals to leave their car. This type of POD can be used in any area that has the capability to accommodate multiple lines of vehicles. A drive-through POD provides excellent social distancing for the public and POD workers in a communicable disease situation. During the pandemic, public health officials here in Jackson actually set up a drive-through testing center at the Braves AAA ball field to accommodate COVID testing to free up clinics and hospitals from testing surges, taking appointments, and manpower from sick patients. A mobile dispensing POD delivers medications to members of a community who are homebound, live in a rural area, or just aren't able to travel to the POD. These are usually run in partnership with Meals on Wheels or faith-based organizations or other organizations. A non-medical POD is for community members who have possibly been exposed to a disease but are not yet exhibiting signs or symptoms, and so prophylactic medicines can be given to help prevent development of the disease. The majority of PODs will be non-medical PODs, staffed with non-medical staff, as likely as medical personnel be allocated to hospitals or alternate treatment centers to care for the sick or critical individuals. Finally, alternative care states might be created to provide care for sick or injured patients. The federal medical station may be requested to outfit the ACS with beds, equipment, supplies. Alternative care states may be used to triage patients and to provide treatment to those that are symptomatic. Those can sometimes be staffed by medical professionals, such as physicians and nurses. So this is the layout of what a POD is going to look like. Once that threat has been identified, the core POD staff will be notified to begin the process of opening a POD. The function number one is intake. This is areas of entrance to the POD where the screening forms are completed for medical countermeasures. Community members are routinely sorted into their proper assistance area during intake, which facilitates a flow through the POD. There are also specialized areas to include family with special needs, an express lane, and then an area that offers translators for those with limited English proficiency. Function two of screening, the appropriate medical countermeasures for each person are determined based on a review of the person's screening form. Screening is often the most time-consuming and staff-intensive area of the POD. Physicians in this area don't necessarily have to be filled by medical personnel. Volunteers can be utilized still as well. After the appropriate medical countermeasures have been determined during screening, community members will continue on to the dispensing to receive their medications or their vaccine. Staff in this area can include pharmacy or medical personnel as well as general staff members. Credentials required for dispensing medication in a POD may vary from state to state. This is the area with the least staff-intensive and should have multiple lines for dispensing medication. The last is exit, which is the point where the community members leave the POD. The exit function serves to ensure everyone has received his or her medical countermeasure and has provided educational and information materials pertaining to the medical countermeasure. In this area, staff members may review resources available for community members in need of behavioral health resources. This area also has staff members overseeing the public safe departure from the POD with their appropriate education materials. Core staff may come from a variety of places, including the public health community, emergency management, volunteer organizations, or the city or government departments. In any large-scale emergency situation, there may be limited availability of human resources at the federal, state, or local levels for POD operation. Therefore, volunteers from within a community can also be trained to work in the POD. This slide lists the types of staff needed to ensure successful operations. The core staff is a group of individuals trained with the competencies to set up and manage the activity of the POD. They also have the ability to train other volunteers for the positions needed, with either just-in-time training or training intended to be applied right away. Affiliated volunteers are attached to recognized volunteer organizations, such as the Red Cross or Medical Reserve Corps. They've been trained for specific disaster response activities. Unaffiliated volunteers are spontaneous members from a community who show up on their own to offer help. They're not part of a recognized system, and therefore they won't have provided their credentials or been registered with an agency prior to the event. They may be asked to actually report to an off-site location or a location with the POD to have their credentials reviewed and receive training before they're allowed to actually help in the POD. And then last is the medical staff and volunteers. The type of medical countermeasures being dispersed at a POD will determine the health medical professional staff needed. Unlicensed volunteers can dispense pills or medication under the oversight of a medical professional. However, when vaccinations or injections are required, they must be administered by an authorized individual, typically nurses, physicians, pharmacists, or other health care providers. So really, during the emergency, it's the scope of practice for medical professionals that determines what's going to be at these PODs. However, states can expand them to allow them to perform functions they don't normally perform. As mentioned earlier, health care professionals can be registered in advance for an event so that their credentials can be verified. And this helps to ensure fast and proper placement within the POD operations. And so one of these, federal government also provides guidance through the emergency systems for advanced registration of volunteer health professionals. Say that five times fast. But these systems help volunteers by keeping their credentials current at all times. And so that allows for a quick response when emergencies occur. There's other volunteers of the staff, as we mentioned, Red Cross, Medical Reserve Corps, but also just civic organizations, faith-based organizations, schools, businesses, just other volunteers who want to come out and help. And we'll also talk just a little bit about partner support because SNS also offers technical assistance, including guidance to assist with SMS planning and access to SNS tools and other resources. They also provide training and tech support. They come out and do preparedness planning, tabletop exercises, really support for the before, during, and then after of any kind of disastrous situation. During response, SNS also coordinates with other federal partners to develop operational planning guidance for these SLTT jurisdictions. Guidance provides information on MCMs available and allocations, process to request, clinical guidance, and et cetera. Once they're finalized, operational planning guidance is then available on ASPR's website for review. In addition to partner support, we've mentioned training support and exercise support. In an interest in time, I'm going to keep going. But there is some information down in the notes section just about what this means and how we get those deployed to local jurisdictions. The last thing that they do for support is technical assistance from the U.S. Marshal Service is available. This includes federal law enforcement services for transportation security, for high value movements and controlled shipments, security planning expertise available to SLTT, and then just coordination of security activities with SNS during an emergency response. So now we get to talk about the fun part, which is the limitations of this system. So we've learned about incident command components of the National Incident Management System in a previous webinar. So during a public health emergency, SLTT and federal agencies need to work together in a standardized approach to allow responders from different disciplines to work together effectively to respond to natural disasters and emergencies. Within that framework of what should happen, we'll discuss limitations to stockpiling. So from an operations standpoint, although there are National Incident Management Systems for handling PHE, during the COVID pandemic, these systems didn't appear to be utilized effectively. Roles between state and federal agencies were not clarified, and this led to competing agencies trying to obtain resources for their constituents, which led to hoarding and inequality in reserves. Tribes, tribal organizations, and urban Indian organizations reported difficulty accessing the SNS during this time. There was unnecessary red tape, resulting in delays in deployment of resources. Then when tribes did receive supplies, the shipments contained wrong or unknown supplies, or they were addressed to the wrong department. One example is a pharmacy was given viral transport medium that could have been used by the lab. The media went unused for several months because no one knew what it was or who could use it. And so there were also gaps in training revealed during the COVID pandemic. Several federal agencies deployed to tribal reservations weren't aware of tribal sovereignty, or the issue that tribes weren't included in the national training exercises in the first place before all this happened. In respect to planning, currently there's no requirement for states, local, tribal, or territorial governments to maintain their own stockpile of medical and ancillary equipment to prepare for and respond to a health emergency. And prior to COVID, ancillary equipment like ventilators were not kept in the SNS inventory. The HHS Secretary is required to review the stockpile contents annually to ensure they are consistent with current threats to health security. To assist in this review, the Secretary works in consultation with the public health emergency medical countermeasures enterprise, the PHMSAE. However, in 2017, ASPR began restructurizing PHMSAE and limiting the scope of its deliberations, so PHMSAE failed to perform its statutorily required annual S&S reviews in FY 2017, 2018, According to the governmental account of office, these reviews would have informed inventory decisions for fiscal years 2020 through 2022. So for those years, S&S purchases were guided by just previous reviews and HHS discretion. As a society, we're pretty poor at anticipating the future and prioritizing future needs. The S&S was more prepared for an in-pox outbreak in 2017 than it was for COVID. 2017 was a time where there was no outbreaks, but much more available vaccine. But risk tolerance changes over time when you're faced with competing priorities and limited resources. When faced with an active in-pox emergence in 2022, S&S did not release all of its in-pox vaccine because of the ever-present competing risk of a smallpox bioterrorist attack. They used predictive risk assessment, wherein the larger catastrophic risk of death by smallpox was determined to be greater than the risk of dispersing the vaccine stockpile for rarely fatal in-pox and allows plenty of current risk versus the potential for future harm. The risk assessment is not an implicit failure of S&S, but rather it's just illustrative of what a challenging, near-impossible task it is to predict what threats are imminent and then accurately scale the response required in a resource-effective manner. The stockpile has had enough smallpox vaccine for a nationwide vaccination campaign, but it was less prepared at the beginning of the COVID-19 pandemic just for universal infectious disease countermeasures such as an N95 respirator and other personal protective equipment. The S&S response to 2009 H1N1 influenza outbreak had depleted all of these supplies, yet HHS repeatedly prioritized the stockpiling of other supplies over the replenishment of PPE and respirators. Nonetheless, had the S&S been replenished to prior levels, the demand from requesting authorities during COVID still likely would have outstripped supply because the S&S has not planned on being able to provide sufficient supplies for a sustained nationwide emergency. The GAO has recommended that HHS develop a formal process for engaging with key stakeholders on a supply strategy for pandemic preparedness, which may help better match expectations to capacity. There are concerns about access and equity related to the S&S. For example, the COVID-19 pandemic, the PPE shortage disproportionately affected women because the PPE stored in the S&S was ill-fitting and designed for men. The needs of society change over time and a stockpile and manufacturers of material it contains are not necessarily responsive to a change in our understanding of and approach to combating health inequities. Additionally, keeping critical medical supplies in a stockpile may be in itself considered hoarding and with every medication that expires while sitting on a shelf in the S&S, was there someone in the United States who needed it? All of this is just to say proper planning is needed for supplies, rotation, and distribution before they expire. With logistics, government responders were able to meet the demands of our vulnerable medical supply chain during COVID through massive feats of logistics. Large volume acquisitions from overseas suppliers, use of the Defense Department stockpiles, and employment of the Defense Production Act managed to meet needs during the PHE. However, those kinds of logistical feats should not be the norm. It depleted DOD stockpiles, which left the potential for armed forces medical readiness to be at a risk should a conflict arise. It placed the power to cut off supplies to the US in hands of foreign governments and global markets. There is a general over-reliance by the US on foreign markets. Half of the world's face masks are made in China. Italy is the largest supplier of swabs used for diagnostic testing, as well as many manufacturer sites of antibiotic are in Southeast Asia. During a global emergency like COVID-19, countries will prioritize the interests of their own citizens and halt exports of critical medical supplies. Flexibility is also needed in logistics. Preemptive purchasing and storage may not be the most effective use of resources, and the government agencies are poor predictors of what needs to be preemptively purchased. An example of flexibility, I don't know if you all can see it with this background, but so during the pandemic, all of our local vodka distilleries switched over to produce as hand sanitizer since there was a shortage. And so those are just some examples of how we can use just our defense act, but also how, you know, different local communities can be able to meet those, those rises of things that are missing without having to rise to the occasion of contacting the SMS. So when we talk about the finance and administrative healthcare products, particular medications, vaccines are expensive, they expire. So that requires thoughtful investment. As discussed, you know, fiscal limitations make SMS an easy target for diverting funds when any other issue becomes a priority. Example if a new or repurposed facility was established to provide surge production during an emergency, there can be a significant regulatory oversight from entities such as the FDA that impact production as well. Lastly, with referencing the impact outbreak in May of 22, the administration at the time stated that vaccines for small park were effective against impact impacts and available for deployment, but the two available vaccines that were in the SNS, only one of those was FDA approved. And guess which one was the majority in stock, not the FDA approved one. There was very few of the actual, the gen genios, which was FDA approved in stock. It was estimated that we would need 132 million doses. And there were only about 56,000 that were made available. So you can see from just a logistic standpoint, operation standpoint, finance administration, there's a lot of moving parts that go in. And so why were large doses of a non-approved FDA medication purchased? Why were expired vaccines left to rot in storage and not accounted for? So there's a lot of improvements that can be happening with our stockpiles. And there's a lot of ideas for what we can do in the future. So when we go to talking about the future and modernization, despite its flaws, SNS represents a commitment to emergency preparedness and we can't lose it. We don't want to get rid of it, but how can emergency preparedness be modernized? Example in the area of era of 3D printing and additive manufacturing, perhaps re-imagining the SNS would entail not hoarding PPE, but instead creating dedicated manufacturing sites that could rapidly tailor outputs to the needs of the emergency response, similar to how the Defense Production Act allows the presidential administration to utilize private manufacturing. So when we look at our key takeaways that we want to get, you know, on this slide, there's context, it's concepts and potential test material. However, the true takeaway about this might affect your current or future practice as a preventive medicine practitioner. I really want you just to understand where you can plug into the emergency framework to obtain technical assistance and resources to help your community. Getting involved with emergency management planning, leading simulated disaster drills for your hospital or clinic, thinking through what medical resources need to be in your go bag if you live in a rural community. These are all the types of scenarios you can begin to work through before your disasters strike. And then just some links for your volunteer organizations. You can also go to ASPR's website to sign up for free trainings through the HHS and the CDC that go through all of these different stockpiles, training, but also just some emergency preparedness in general if you're interested in those things. So thank you very much. This QR code is connected to just my socials and information. So if we don't get a chance to answer any questions, because I'm looking now that I went a few minutes over my allotted time. So feel free to reach out and we can answer any questions that you may have. So, Dr. Brett, we actually have time. We go until eight o'clock and there are a couple of questions. Are you? Yeah. Go ahead. OK, perfect. So the first question is we discovered that there are AI products designed to assist with evacuation during natural or manmade disasters. Have you had any experience with these tools? What kind of inputs do they require? How does the AI gather or determine this information? Is it based on historical disaster data such as the number of injuries, property damage or other factors related to life, safety and assets? Did the developer providers developers provide users with an explanation of how this information is calculated? And additionally, how widely is this type of software used? The answer is yes to most of the questions, most of those scenarios. So we have not it's not actively deployed through like through Medicaid. We are exploring how we can use AI machine learning for identifying risk cohorts. And so that kind of information could be transferred to emergency management. But when we talk about why it might not be, there's a lot of logistical steps. There's a lot of, you know, protected health information. There's a lot of steps along the way that legal, you know, they start talking and it goes and sits on their desk for a long time before it actually gets into production because there's a lot of moving parts and a lot of steps. Also, when you talk about, you know, any kind of technology, you know, what are the systems that talk to each other? You know, all the hospitals have EHR, but they don't talk to each other, much less, you know, different government agencies, outpatient, inpatient, you know, emergency management, all of these moving parts. So there's a lot of technical components to get everybody from an intercom, you know, compatibility operational standpoint to be able to utilize that. But I think it's really exciting for the future. You know, we use a lot of AI and machine learning for looking at medical cohorts in the insurance industry and medicine. So I think that definitely could be applied elsewhere. It's just getting all those little moving pieces. You know, the machines talking to each other to be able to disseminate that information is where, you know, that next step is for getting it out there. Thank you, Dr. Brett. And final question, and please keep the questions coming. But for now, the question we have is, are simulation exercises or drills used to evaluate the readiness and effectiveness of deploying stockpiles in real emergencies? I would say yes. So when I was in residency, I actually rotated through emergency management for our hospital. We were able to work through. We had an eclipse that happened, so we were able to go out in the community and so really work through, you know, what resources would we need? How many people do we anticipate being, you know, hurt? Do we have enough bandages? Do we have enough of this? Where would we go? What would be the steps if we exhaust all of ours? How would we contact? Who do we need to, you know, notify? And so we would do a lot of tabletop activities for, you know, whether it was natural disasters, whether it was something terrorism. And so I think any kind of those scenarios, those either with a tabletop or, you know, actual, you know, simulations where you're really working through and going through the different departments, it's important to know because a lot of times you'll come across something and you'll go, oh, I didn't realize we didn't have this. Or, oh, I needed to go find X, you know, and I had no clue where they were located. I would have thought they'd be in the surgical bay, but they were over in behavioral health, you know, and let's remove those over. So I think there's a lot of utilization when we talk about doing those simulations. And that helps us to know who we need to contact ahead of time because it's not just waiting for when you actually are out of supplies, but you can forecast, hey, I see this happening. I think we're going to run out by next Tuesday. Can we go ahead and get this deployed? So it's really important to know what you already have and know, you know, how many people that's going to be able to cover so that you can be able to forecast those things for asking for resources later. We've got one additional question in the chat. Can you reiterate how local state authorities activate the strategic national stockpiles based on need? Yeah, so really the public health department is who kind of activates that process. So that doesn't mean they're the only ones who can activate it. But if I'm at the hospital, I have to get in contact with them to get that process started. And so after they've identified the need, they've identified exactly what those resources are. Then they send that over to the state government. So usually that's the governor who's going to review that, what the needs are, and then goes up the chain. So that then goes to Homeland Security and the Homeland Security and HHS review. Is there a real risk? What's going on? And then they approve that. So that's kind of the chain of how it goes from the public health department then to the governor. Usually the governor's then kind of kind of cycle back to whoever the, you know, the state public health officer to really confirm that. But then that then gets sent directly through up to the Department of Homeland Security and HHS to get all the deployment of the actual resources. And then we have a couple of additional questions. I assume mass federal layoffs proposed by the incoming administration will affect emergency preparedness in knowing resources and how to access them and keeping them updated. What can they do to insulate our stockpile situation from this? Well, you know, the short answer is, you know, the only thing that we have control of is what we have control of. Right. And so if there's going to be changes to the national stockpile, whether administration or what's there. But for instance, local hospitals keep stockpiles, you know, especially after the COVID pandemic. You know, we individually stock IVs, antibiotics, PPEs, things that, you know, you know, ventilators, making sure we have plenty to be able to handle needs. So we don't have to go outside knowing we're in your community. You know, when we had just, for example, a formula shortage, which is not necessarily public health emergency unless you're a baby and you need to eat. But, you know, knowing what are the community resources, knowing who with care management, we would contact other states to see if they could send things over. It's a lot of collaboration. And so, again, that's where, you know, having the simulation so that you know who you're talking to. What are other resources? What are other community? Who is at the table participating ahead of time? And that's who we're going to call on now if we have difficulty with other sources. So I think even with staffing going down, that's why there's such an importance in volunteers. And so the best thing that we can do as preventive medicine physicians is make sure that, you know, we're registered, our peers are registered with these organizations. So that way, if there is an event, if there is an emergency, that we that there won't be any red tape and being able to go and being able to help. Thank you, Dr. Brandt. We've got one more question. Keep them coming. We have four more minutes. Do you have any experience with the Medical Reserve Corps? Would you recommend it for us as preventive medicine trainees and later in our careers? The short answer is I do not have access with it directly. I've had a lot of friends who've gone into that. I haven't heard anything bad as far as exactly what those how that would be different than other medical training or other American Red Cross or these other volunteers. I'm not sure, but I do know that ASPR has a whole webinar that that goes through what those are and those different things. But I think if that's an interest that you have, I think it never hurts to go ahead and, you know, look into it, sign up for it. You know, if there's free training, you know, look in the fine print to see what you're required to do, because, you know, some of those when you get the course, there's there's certain things, you know, you have to meet. However often or come to so many, you know, events throughout the year. So if you don't have the timing to do that, but, you know, I think getting more education, getting more training, getting more preparedness is never a bad thing. So I say that, you know, again, I don't know specifics with that one, but having volunteered in other areas or volunteered with my local emergency management, I learned a lot of things that I normally I wouldn't have. And that, you know, was able to translate into other areas, you know, in other careers. So. And if I may just quickly add, because I was a medical resident here for my local county health department. And again, it would be and I'm not a physician, but I do have a public health background. So I think it's incredibly important, you know, for physicians, it's a wonderful resource. So I think what I did was reach out to the local county health department to see if you can get trained. And this was several years ago. So Dr. Brett's point, I don't know what training requirements have changed since COVID for volunteers to be a part of the Medical Reserve Corps, but I do think that it's a wonderful opportunity, especially to be involved at the local county level. And we do have more questions coming in. One more question. Dr. Odak says, how do national asks, how do national stockpiles balance resources for acute emergencies versus long term public health needs, such as chronic disease prevention supplies. Right. Um, that is a very good question. And I think the answer would be they don't balance that very well. You know, that that was kind of a lot of the research when I was helping to prepare for this talk is that, you know, January one, here's our budget. But then, you know, we start siphoning that off or here goes something else. Or, you know, you haven't used your whole budget this year. So now we're not going to give you that much next year. Well, we want to keep the reserves for those, you know, acute emergencies and things. And so what happens is people start spending their budget just to use it by the end of the year. And then we get, you know, 20,000 gowns that expire because they were just sitting in a cave somewhere. And so I think it's a very careful balance. And that's why it's so important that you're continually assessing what's going on. What is the risk? What is the needs? And why is this a priority and making sure that people sitting at the table do you know you need on all sites, you need to have, you know, the accountants, you need to have the clinical people, you need to have all of them sitting there and talking. So that way we each go, well, this is why it's important to have this many smallpox vaccines, even though it's been eradicated in theory. And so, you know, well, this is how much they cost and to be able to have those conversations because it is a back and forth. You know, there's a limited pot of money. Although, again, I, you know, when they say limited and it's $845 million, I'm like, that still seems like a pretty good pot of money for me. But, you know, one year, the $2 billion was taken away. So even more than what they had was taken away and put somewhere else. So I think it's why we have to have oversight. It's why we have to be continually, you know, evaluating the system to make sure that when we borrow something, it doesn't come back and hurt us later and that we have those backups to be able to say, okay, we can borrow this or we can move this away because we have XYZ over here, but let's follow it up next year to make sure that that's still the case and that doesn't become the norm. Thank you, Dr. Brett. I think there's one more slide. We're at eight o'clock. So if you could just move to the next slide. Thank you all for the great questions. Keep them coming on Pulse. Continue the conversation on Pulse. We do have the next webinar on December 5th, Thursday, where Peter Pendergrass, Program Director from UT Tyler will be presenting on natural disasters. As you can see, we've designed these topics to build one on one another. So we'll hope to see you all in the next lecture on December 5th. And we've posted the link on the chat for you to register if you haven't already registered. With that, again, as Dr. Brett's previous slide had a QR code for her socials and connection, please reach out to her. And yes, the slides and the recording will be made available to all residents. Thank you, everybody. Thank you. Have a great night.

public health emergency preparedness

preventive medicine residents

strategic national stockpile

Administration for Strategic Preparedness and Response

medical countermeasures

chemical biological radiological nuclear

natural disasters pandemics

logistical issues

AI in disaster management

response system