Oct 15, 2008 (CIDRAP News) The Rand Corp., responding to a request from the US Department of Health and Human Services (HHS), recently unveiled a set of proposed standards for cities to use as they establish plans to distribute antibiotics to the public in the event of a bioterrorist attack or other public health emergency.
The 133-page technical report, which appears on Rand's Web site, covers four main topics: the number and location of points of dispensing (PODs), internal POD operations, staffing, and security. PODs are places where members of the public would go to receive antibiotics or other countermeasures in an emergency.
The Pandemic and All-Hazards Preparedness Act of 2006 requires HHS to develop performance standards for public health preparedness, and the HHS Office of the Assistant Secretary for Preparedness and Response (ASPR) asked Rand to develop the proposed standards, according to the report.
The standards are geared toward 72 cities that take part in the federal government's Cities Readiness Initiative (CRI), a program launched by the Centers for Disease Control and Prevention (CDC) in 2004 to prepare major cities and metropolitan areas to distribute antibiotics from the Strategic National Stockpile within 48 hours of a federal order to release them.
Though federal law mandates that the standards be evidence-based, the Rand authors pointed out that the rarity of large-scale public health disasters means there is little evidence to base the standards on. Instead, the authors developed the standards by talking to practitioners, reviewing existing literatures, using mathematical modeling, and seeking feedback from an expert panel.
The standards are designed to allow communities to be flexible and innovative in how they meet the 48-hour dispensing goal, the report says. "Moreover, the standards are intended to provide minimal requirements and should not discourage CRI sites from exceeding them," it states.
Number and location of sites
The authors recommend that the first planning step be to estimate the overall number of people who will likely come to PODs to pick up their medications, which will help them determine the number of PODs they will need. Estimating the number of people will likely depend on several factors that vary by location, such as tourism levels and the size of the urban workforce.
"The standard assumes that individual jurisdictions are in the best position to define the scope of the population for whom they will be responsible for administering prophylaxis," the Rand authors wrote. They also advised planners to factor in 12 hours for the CDC to get the drugs to warehouses and 12 hours to get the drugs to PODs.
Internal operations
The scale of the public health emergency will likely guide the selection of a dispensing protocol, and the report acknowledges the need for flexibility as cities make their operational plans. But the standards would require cities to establish and exercise at least one rapid-dispensing protocol that minimizes the need for licensed medical workers and gives instructions for directing recipients through the process, selecting the medication to dispense, releasing information about the medication, and dispensing the medication.
Because rapid drug-dispensing actions are likely to push legal and liability boundaries, the standards require city officials to identify such conflicts and communicate them to those who have the authority to initiate legal changes.
Staffing provisions
The authors predicted that recruiting adequate staffing for the PODs would probably be the most difficult aspect of conducting a mass dispensing operation and would present diverse challenges in different cities. "The standards development process revealed concern that uniform, one-size-fits-all staffing standards would fail to account for community differences, unnecessarily require jurisdictions to undo work already completed, and stifle innovation," they wrote.
Instead of setting targets for numbers of PODs, the standards call for cities to estimate the number of people who would go to individual PODs seeking antibiotics. Officials would then use a formula supplied in the report to determine how many PODs would be needed.
Public health officials will also need to recruit enough staff to operate the PODs and perform quarterly drills to keep in contact with them. The authors said the staffing requirement may be very large for some locationsas many as 6,000 in some metropolitan areasso they offered an alternative standard under which officials would recruit and regularly contact only the core staff.
Security concerns
The standards would require cities to assess security at each POD, involve local law enforcement agencies in developing security plans, and provide for law enforcement presence at each site.
In another nod to varying local needs, the authors give cities some leeway in the form of alternative standards regarding security staffing and formal law enforcement approval of security plans. For example, cities could use trained volunteers of private security firms if having sworn officers at every site were not feasible.
Next steps
The Rand authors suggest that HHS officials review the suggested standards, consider if changes are needed, then move forward to enact the standards. They also suggest that HHS consider whether the standards should apply to all locations that would receive antibiotics from the SNS, not just the 72 cities that participate in the CRI program.
Another suggestion is that HHS establish an oversight committee to regularly review the standards in a way that engages stakeholders, seeks public input, and includes an appeal process.
See also:
Rand report on proposed antibiotic dispensing standards
