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OCR for page 241
Appendix D
Commissioned Paper:
A Cost and Speed Analysis of
Strategies for Prepositioning
1
Antibiotics for Anthrax
James Guyton, Principal, PRTM, lead author
Robert Kadlec, Chandresh Harjivan, Shabana Farooqi, Sheana Cavitt,
and Joseph Buccina, PRTM, co-writers and contributors
This paper was prepared by PRTM Management Consultants, LLC (PRTM)
under a contract with the Institute of Medicine (IOM) and submitted in April
2011. This publication is limited to the approach and analysis described
herein and on information available as of April 15, 2011. No representation
or warranty (express or implied) is given as to the accuracy or completeness
of the information contained in this publication, and to the extent permitted
by law, PRTM and its members, employees, and agents do not accept any
liability, responsibility, or duty of care for any consequences of the Commit-
tee or anyone else acting, or refraining to act, in reliance on the information
contained in this publication or for any decision based on it.
INTRODUCTION
Currently, the United States Government (USG) stores the vast majority
of its contingency medical countermeasures (MCM) in 12 centralized loca-
tions as part of the Centers for Disease Control and Prevention’s (CDC’s)
Strategic National Stockpile (SNS); adopting the concept of prepositioning
could alter this modus operandi. Prepositioning for public health prepared-
ness is the placement and storage of MCM in caches that are geographi-
cally closer to the metropolitan areas and the corresponding populations at
1 Thispaper was commissioned by the Institute of Medicine (IOM) to provide background
for the deliberations of the Committee on Prepositioned Medical Countermeasures for the
Public. The responsibility for the content of this paper rests with the authors, and the paper
does not necessarily represent the views of the IOM or its committees and convening bodies.
241
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242 PREPOSITIONING ANTIBIOTICS FOR ANTHRAX
risk. The primary goal of prepositioning is to increase the speed of MCM
distribution and dispensing during a high-consequence biological incident.
In the event of an attack with aerosolized Bacillus anthracis (anthrax),
administering oral antibiotics immediately following exposure has demon-
strated the potential to save lives (Friedlander et al., 1993). Anthrax exists
in vegetative and spore forms. The spore is an extremely hardy, dormant
form of the bacterium; it can persist for decades in the environment. When
a spore enters a live host, it transforms into its vegetative, disease-causing
state. Once active, anthrax produces toxins that are lethal. Given its high
lethality and potential ease of acquisition, production, and dissemination,
the release of aerosolized anthrax is the type of high-consequence biological
attack that is of most concern.
The Center for Biosecurity at the University of Pittsburgh Medical
Center notes that anthrax is considered one of the most serious bioterror-
ism threats for the following reasons (UPMC Center for Biosecurity, 2007):
• widespread availability of starter cultures in culture collection
banks around the world;
• widespread natural availability in endemic areas;
• wide commercial availability of equipment and techniques for mass
production and aerosol dissemination;
• robustness of anthrax spores, making anthrax easier to weaponize
for aerosol dissemination than other biological agents of concern;
• high fatality rate in untreated inhalational cases;
• relatively low infectious dose, based on nonhuman primate animal
data;
• risk of antibiotic-resistant strains that exist in nature or that may
be easily cultivated for use in an intentional release; and
• recent use of anthrax during the 2001 Amerithrax attacks.
During the 2001 Amerithrax attacks, the median incubation time for
inhalational anthrax was 4 days (Jernigan et al., 2001). It is estimated that
if oral antibiotics are not administered before the onset of clinical symp-
toms, the mortality rate, even in intensively treated cases, could potentially
exceed 90 percent (UPMC Center for Biosecurity, 2007). In the few inhala-
tional anthrax cases treated in 2001, intensive clinical treatment resulted in
a mortality rate of 45 percent (Jernigan et al., 2001). Depending on the ini-
tial infective dose and when the exposure is detected, the effective window
for antibiotic administration may be considerably less than 96 hours. As a
matter of USG policy, current requirements have set the objective of deliv-
ery of oral antibiotics to potentially exposed individuals within 48 hours of
the decision to do so (CDC, 2010a). Prepositioning can enable more rapid
dispensing of oral antibiotics following an anthrax attack, thus increasing
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243
APPENDIX D
the likelihood that a larger proportion of infected individuals will receive
antibiotics during the asymptomatic incubation period.
The Institute of Medicine’s (IOM’s) Committee on Prepositioned Medi-
cal Countermeasures for the Public commissioned this paper to provide
background for its deliberations on prepositioning strategies for anthrax
antibiotics. PRTM analyzed three prepositioning strategies:
• caches in hospitals and pharmacies;
• caches in workplaces of different types (e.g., state and local gov-
ernment, private infrastructure, Fortune 50 companies, small busi-
nesses), schools, universities, daycare centers, and institutional
facilities for older adults (for simplification, the PRTM team cat-
egorized these into large and small places of work); and
• approved MedKits (or similar dose packs) stored in individual
households and intended for use by occupants.
This paper focuses largely on two variables: the cost of each preposi-
tioning strategy, and the time to antibiotic distribution and dispensing. The
paper also examines the implications of these strategies in three different
settings: urban, suburban, and rural. PRTM chose the Minneapolis-St. Paul
metropolitan statistical area (MSA) as a case study because of the avail-
ability of relevant cost and delivery time data and its confluence of urban,
suburban, and rural environments. The prepositioning strategies are com-
pared with two scenarios:
• The current approach of SNS to receiving, storage, and staging
(RSS) sites to points of dispensing (PODs)—This approach serves
as the baseline model.
• The postal distribution model—In 2008, federal health officials
announced the beginning of a postal distribution pilot project in
the cities of Minneapolis and St. Paul (Roos, 2008). In this model,
postal workers deliver antibiotics directly to individuals’ homes in
the event of an anthrax attack.
Other approaches also are considered in the section below on alterna-
tive dispensing strategies, including a forward-deployed SNS model and
vendor-managed inventory. In addition, in the course of this effort, PRTM
uncovered several areas for additional consideration, which are highlighted
in a later section. Note that detailed data on which the discussion of the
various dispensing strategies is based are presented in Appendix D.1.
In conducting research for this paper, PRTM performed an extensive
review of open-source literature and interviewed more than 40 subject mat-
ter experts. Appendix D.2 provides a list of interviewees.
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244 PREPOSITIONING ANTIBIOTICS FOR ANTHRAX
STRATEGIES FOR PREPOSITIONING
This section provides a brief background on CDC’s current strategy for
distribution and dispensing of antibiotics and a description of each prepo-
sitioning strategy. The current approach, based on PODs, is the standard,
practiced model for delivering MCM, such as oral antibiotics and vaccines,
to an impacted locale following a biological attack. This model is the back-
bone of several MCM dispensing strategies that were reviewed. Whereas
the prepositioning strategies are intended to increase the speed with which
a 10-day supply of oral antibiotics is delivered, they are intended only as
an adjunct to the POD dispensing approach. The SNS-RSS-POD approach
serves as the principal means to distribute and dispense the remainder of
the full 60-day course of antibiotics, and vaccination as necessary, to all
those affected.
Current Approach for Distribution and Dispensing: Points of Dispensing
The current distribution and dispensing model (Figure D-1) is managed
by CDC in conjunction with state, local, and tribal health departments.
Antibiotics and other MCM are stored in 12 undisclosed locations across
t he United States in the SNS. The exact amount of antibiotics stored
in these caches is not made public, for security reasons. In the event of an
attack, CDC guarantees the delivery of a “Push Package” of medical mate-
rial, including oral antibiotics, to the affected location within 12 hours of
a request (CDC, 2010b). A Push Package is a large package of medications
and other medical supplies that can be transported quickly from one of
the SNS locations. The oral antibiotics (approximately 500,000 doses in
the Push Package) are intended to be an initial supply. Additional quanti-
ties of oral antibiotics are transported to the area from a larger reserve
contained in a vendor-managed inventory, or inventory controlled by the
manufacturer that is guaranteed to be available to the federal government
upon request.
Once the Push Package has been transported from the SNS, state
authorities receive it at a predesignated RSS site. At this point, the MCM
are transitioned from federal to state control. The RSS staff unpacks the
FIGURE D-1
Strategic National Stockpile (SNS) to receiving, storage, and staging (RSS) sites to
points of dispensing (POD) model.
NOTE: The star denotes where the antibiotics are stored.
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245
APPENDIX D
medications and transfers them to trucks, which are bound for individual
PODs. The amount of antibiotics delivered to each POD is predetermined
by the estimated number of people to be served by each.
Once the antibiotics reach the PODs, they may remain under state
control or be turned over to local (county or city) control, depending
on the jurisdiction. Although the conceptual approach was developed by
CDC, the PODs’ actual operation and staffing are determined by the state
or local jurisdiction. At the PODs, public health practitioners screen the
public for contraindications to the antibiotics, educate them on the use of
the antibiotics, and then dispense a 10-day supply to each person. Different
jurisdictions employ a variety of approaches to increase throughput, such as
having the head of the household retrieve drugs for everyone in that house-
hold, as one interviewee from Tennessee indicated, or having the necessary
paperwork completed before a potential event to avoid time spent filling
out forms during an emergency, as an interviewee from New York noted.
Caching in Hospitals and Pharmacies
Prepositioning contingency antibiotics in hospitals and pharmacies
(Figure D-2) would effectively result in increasing the on-hand antibiotic
supply beyond current inventories for routine use in such facilities. Gen-
erally, hospitals and pharmacies stock enough antibiotics to meet their
immediate daily needs. They rely on distributors to continuously provide
“just in time” supplies of antibiotics so they have enough stock to fill their
needs, but not so much that they have extra stock on hand. Notable
e xceptions to this practice are Department of Veterans Affairs (VA)
hospitals, Department of Defense (DOD) medical treatment facilities, and
some private hospitals that maintain a limited stockpile to provide to their
staff and patients in the event of a biological attack.
Expanding this practice to all hospitals, and possibly clinics, would
require significant increases in their stock on hand and the costs associated
with excess inventory. While they would likely still use the first-in/first-out
FIGURE D-2
Hospital/pharmacy prepositioning model.
NOTE: The stars denote where the antibiotics are stored.
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246 PREPOSITIONING ANTIBIOTICS FOR ANTHRAX
approach to lessen the impact of expiry, actual costs associated with expiry
would depend on the ratio of the size of the cache to the turnover volume
of routine use of the antibiotics.
While hospitals, clinics, and pharmacies could maintain contingency
antibiotic stockpiles, the manner in which those institutions could dispense
such products would be significantly different. Hospitals would serve only
as closed PODs. A closed POD is a location that is not open to the general
public, but is set up to serve a predefined population. Hospitals would
provide prophylactic antibiotics only to patients, staff, and families of staff.
This practice would increase the likelihood that essential hospital workers
would report for duty. Limiting dispensing to hospital personnel would
be intended to maintain operations for treating current patients and
those who needed treatment during the emergency. This dispensing strategy
would not accommodate the general public, who, if they sought such treat-
ment, would likely inundate the facility and possibly render it incapable of
performing its essential functions.
In contrast, pharmacies and some clinics could serve as open PODs.
They would be able to dispense antibiotics to the general public during an
emergency. One advantage of this model is that pharmacies and clinics are
numerous and have high prevalence in the United States, and people have
a general familiarity with the location of their local pharmacy or neighbor-
hood clinic. This approach, however, would require that pharmacies rapidly
package antibiotics for swift dispensing, as opposed to routine operations
whereby prescriptions are filled on an ad hoc basis.
Hospitals, pharmacies, and some clinics already have some security
measures in place for safeguarding medications, so during nonemergencies
they likely would not incur an incremental security cost. However, in the
event of a biological attack, additional security would likely be necessary
to augment existing security activities during dispensing operations. Hos-
pitals, clinics, and pharmacies also would have medical staff on hand who
would be licensed to dispense antibiotics and could conduct the necessary
prescreening of patients.
Caching in the Workplace
Prepositioning in workplaces (Figure D-3) would effectively create
additional closed PODs. In this approach, private companies would stock
enough antibiotics to dispense to their employees during an emergency. It
would be the company’s decision whether to also provide antibiotics to em-
ployee families. The manner by which private companies could participate
is two-fold. They could purchase and store antibiotics on site themselves,
or they could identify themselves to local public health authorities to serve
as a closed POD. In the latter case, the local authorities would provide the
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247
APPENDIX D
FIGURE D-3
Workplace prepositioning model.
NOTE: The stars denote where the antibiotics are stored.
antibiotics to the workplace by way of the SNS. The former approach,
prepositioning on site, would offer the advantage of decreasing the time to
dispensing. Serving as a closed POD would not necessarily increase speed
over the baseline because no prepositioning would be taking place, and the
delivery of antibiotics to the workplace would be contingent on the speed
of delivery of the SNS assets.
Caching in workplaces would effectively decrease the percentage of
the population that would have to be serviced by public PODs. Employees
would benefit from being able to access antibiotics from a familiar place.
However, workplaces would likely need to bring in medical personnel for
screening and dispensing if they did not already have medically trained
personnel on site. Alternatively, the workplace could conduct prescreen-
ing of personnel before the event, a practice that was performed in one
interviewee’s workplace. This approach might allow the antibiotics to be
dispensed by nonmedical personnel following an anthrax incident.
Caching in the Home (MedKits)
Prepositioning antibiotics in the home would entail providing MedKits
to a predefined segment of the population within a certain area (Figure D-4).
In lieu of a Food and Drug Administration (FDA)–approved MedKit or an
over-the-counter product, a prescription would be required for each recipi-
ent’s doctor, or recipients would have to be subject to some screening by
a health care worker before the MedKits could be issued. This approach
would involve screening every person prior to dispensing to determine
contraindications, such as allergies, and dosing changes. The appropriate
type and numbers of bottles of antibiotics would then be shipped to every
household. These bottles would be encased in plastic bags with instruc-
tions on storage and use of the antibiotics. Each bag would contain enough
antibiotics to cover each person in the household for 10 days. Figure D-5
shows a depiction of a home MedKit.
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248 PREPOSITIONING ANTIBIOTICS FOR ANTHRAX
FIGURE D-4
Home MedKit prepositioning model.
NOTE: The star denotes where the antibiotics are stored. USPS = U.S. Postal Service.
FIGURE D-5
Depiction of a home MedKit.
SOURCE: CDC, 2008.
CDC conducted a study in which it dispensed MedKits to a predefined
population in St. Louis to determine how MedKits would be handled and
whether people would appropriately follow the instructions provided
(CDC, 2008). It was found that the large majority of the population
(97 percent) did not use the antibiotics inappropriately and returned the
MedKits intact. The study also showed that people had a generally posi-
tive response to the MedKits and felt more prepared having one in the
home.
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249
APPENDIX D
The advantage of this model is speed of dispensing in response to
an event. The public could be alerted and begin taking the antibiotics
immediately without needing to leave their homes. However, many vari-
ables could impede the effectiveness of this model. These include little or
no medical oversight of prescription medications, loss of the medication,
incorrect storage, compliance and tampering, product expiry and returns,
and inappropriate usage during other periods of illness. Because of the risk
of antibiotic-resistant strains of anthrax, moreover, it could be necessary
to have multiple types of antibiotics in the MedKit, which would further
complicate the use of this approach.
Postal Distribution Model
One additional model used in this study for comparison is the postal
distribution model (Figure D-6). This model is a variation on the standard
SNS-RSS-POD model. Rather than the pull approach of that model, the
postal distribution model serves to push MCM out to the population. The
pilot for this model was sponsored by the Cities Readiness Initiative (CRI)
and was employed in the Minneapolis-St. Paul MSA.
In this model, the medications are shipped from the SNS to the RSS,
as in the standard model. From there, the medications are delivered to the
postal service rather than to PODs. The medications are then delivered to
residences in the affected area by postal workers, who agree to deliver the
antibiotics on a volunteer basis. In exchange, they are given one MedKit
for their home and one for work to cover them and their families. During
an emergency, the postal workers would report to the postal service and
receive enough MCM to cover approximately two normal routes, as well
as a security escort. They would then deliver one bottle of antibiotics to
each household on the predetermined routes (Plessas, 2010). As the postal
workers cover these routes every day, they are trained to make these deliv-
eries and have done so with efficiency in limited-scope trials in Seattle,
Boston, and Philadelphia.
FIGURE D-6
Postal distribution model.
NOTE: The stars denote where the antibiotics are stored. USPS = U.S. Postal Service.
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250 PREPOSITIONING ANTIBIOTICS FOR ANTHRAX
ANALYTICAL FRAMEWORK
PRTM used the analytical framework shown in Figure D-7 to compare
the above dispensing models. In conducting the analysis, the PRTM team
sought to compare the different prepositioning strategies included within
the scope of this paper with the current SNS-RSS-POD baseline. To accom-
plish this, the team estimated total costs associated with:
• product,
• transport,
• inventory management, and
• dispensing.
For each dispensing strategy, the team examined the time required to
dispense antibiotics from the cache to the subset of the population served,
as well as the total time required to dispense antibiotics to the general pub-
lic using a combined SNS-RSS-POD and prepositioned cache strategy. By
measuring the SNS-RSS-POD baseline, the team was able to estimate time
savings over the baseline, as well as time savings per dollar spent for each
prepositioning strategy.
It is important to note that the time savings referenced above apply to
the subset of the population served by the various prepositioning strate-
gies. According to a Georgia Institute of Technology study, 20 percent
participation by the private sector is a reasonable goal, taking into con-
sideration anticipated reluctance to participate (Lee, 2011). As a result,
the team estimated that 20 percent of the population would receive an
Current SNS-RSS-PODs baseline,
with comparison to prepositioning strategies
Administration # required to Cost to cache Time to Time savings
Strategy administer to (build and manage administer to over baseline
population stockpile) per population
capita (throughput)
—
SNS-RSS-PODs
(baseline)
Minneapolis-
Hospital and
St. Paul
pharmacy caches
population :
Comparison across strategies
1,700,000 Workplace
caches
Home caches
(MedKits)
FIGURE D-7
Analytical framework.
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251
APPENDIX D
initial dose of MCM through prepositioned caches at workplaces or
hospitals/pharmacies, while the remaining 80 percent would still need to
receive MCM through PODs. For those scenarios, referenced time savings
are therefore applicable only to the 20 percent of the population that would
receive MCM through the prepositioned caches. In addition to enabling
initial time savings, prepositioned caches would help alleviate the burden on
PODs by decreasing the total number of individuals that would visit PODs
to receive their initial dose of MCM.
To allow for additional analysis and comparison, the team reviewed
cost and speed implications associated with employing the postal model in
the Minneapolis-St. Paul MSA. To facilitate an accurate comparison, the
team assumed the same treatment and dosage as planned for the postal
model (consisting of an initial treatment course of 10 days, with two pills
per dose), as well as the same target population (the Minneapolis-St. Paul
postal plan is intended to serve residents in 20 zip codes, with a combined
population of 1.7 million individuals), according to estimates provided by
interviewees.
COMPONENTS OF COST AND SPEED
FOR DISPENSING STRATEGIES
PRTM assessed each strategy by taking into consideration three key
variables: (1) total population served, (2) total cost, and (3) total speed of
dispensing. The following sections decompose the general methodology
employed by the team, including major assumptions, to derive the estimated
population, cost, and speed for each strategy assessed. Additional detail on
these calculations can be found in Appendix D.1.
Total Population Served
Both total cost and speed will vary greatly depending on the expec-
tation of the total population to be served by each dispensing location.
Table D-1 lists the PRTM team’s assumptions related to estimating the
population served.
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TABLE D.1-6
308
Continued
Postal Component
Description Data Calculations
Dispensing
Dispensing - Labor - Postal workers [(2,540 workers × 8 hours × 23.72/hr) +
$843,483.20
(2,540 workers × 4 hours OT wage [1.5
regular])] - 332.08 per worker
Dispensing - Administrative Fees/Operational Costs $23,000 per zip × 20 zip codes (source:
$460,000
Interview with federal official)
Dispensing - Security (per officer) $406.16 12 hour shift, 8 regular/4OT, for MnSP
using BLS rate of $29.01/hr
Dispensing - Security needs (# of officers) 2,540 2/3 (volunteer rate) × 3,810 (total USPS
carriers in MnSP) - (source: interview
with federal official)
Dispensing - Security (total) 2,540 × $406.16
$1,031,646.40
(Labor - postal workers) + (Dispensing -
Dispensing - Total Costs $2,335,129.60
Administrative Fees/Operational Costs)
+ (Dispensing - Security)
Inventory Management
Inventory Management - Labor
Inventory Management - Cost of Storage/Pallet
Inventory Management - # of Bottles/Pallet
Inventory Management - # of Pallets Required
Inventory Management - Storage (total)
Inventory Management - Total Costs (excluding
replenishment costs)
OCR for page 309
Postal Component
Description Data Calculations
Inventory Management - Replenishment - Total Costs
for Medication (total postal dispensing)
Inventory Management - Replenishment - Total Costs $42,655.74 [2,540 workers × 2.28 MedKits (for
for Postal Workers’ MedKits household) × $5.12 per MedKit] + [2,540
workers × 1 MedKit (for work) × 5.12 per
MedKit]
Inventory Management - Replenishment - Total Costs
for Product Purchase (overall)
Inventory Management - Replenishment - Labor - $0.00
Postal workers
Inventory Management - Replenishment - Security $0.00
(total)
Inventory Management - Replenishment - Total Costs $0.00
for Dispensing
Inventory Management - Replenishment Costs
(total)
Dispensing Time
Dispensing Time - Postal Dispensing (hours) (source: interview with federal employee
12
and Georgia Tech paper)
Dispensing Time - SNS to RSS to Postal Office (source: calculations derived from
13.24
Transportation (hours) presentation - G. Burel. An SNS
Perspective on Pre-positioning Medical
Countermeasures. Centers for Disease
Control and Prevention, February 28,
2011. Presented to IOM Committee on
Prepositioned Medical Countermeasures
for the Public)
309
continued
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TABLE D.1-6
310
Continued
Postal Component
Description Data Calculations
Postal Dispensing (hours) + SNS to RSS
Dispensing Time - Total (hours) 25.24
to Postal Office Transportation (hours)
Total Costs - Postal (43.82%, 745,000 doses/
households)
Product Purchase Price
Transportation $0.00
Dispensing $2,335,129.60
Inventory Management
Total Cost (without replenishment) $3,495,285.34
Replenishment Costs (annual)
POD Component Data Calculations
Costs
Individuals 955,000
Households 418,859.65
Product Purchase Price
Product Purchase Price - Costs per daily dosage
- Propylaxis, Doxycycline
Product Purchase Price - Additional Medication Costs
Per Daily Dosage (packaging, etc.)
Product Purchase Price - Total Costs for Medication
Per Daily Dosage
OCR for page 311
POD Component Data Calculations
Costs
Product Purchase Price - Total Costs for Medication
(per household)
Product Purchase Price - Total Costs for Medication
(overall)
Transportation
Transportation - SNS to RSS to Postal Office N/A not available
not available
Transportation Costs (overall) $0.00
Dispensing
Dispensing - Labor - Salaries (per POD, per day) $44,736.00 300 staff per POD/day (source: interview
with state department of health official)
× 8 hours/day × $18.64/hr (source: Zaric
et al.)
Dispensing - Labor - Salaries (20 PODs, per day) $894,720.00 Labor per day per POD × 20 PODs
Dispensing - Labor - Salaries (total) 20.94 hours × 1 day/24 hours ×
$780,643.20
$894,720/day
Dispensing - Labor - Training (annual) 300 staff per POD × 8 hours of training/
$894,720.00
yr × $18.64/hr
Dispensing - Administrative Fees/Operational Costs $5,000.00
(daily, per POD)
Dispensing - Administrative Fees/Operational Costs $100,000.00 $5,000 × 20 PODs
(daily, 20 PODs)
Dispensing - Administrative Fees/Operational Costs 20.94 hours × 1 day/24 hours ×
$87,250.00
(total) $100,000/day
Dispensing - Security (daily, per POD) $2,784.96
Dispensing - Security (daily, 20 PODs) $55,699.20
311
continued
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TABLE D.1-6
312
Continued
POD Component Data Calculations
Costs
Dispensing - Security (total) 20.94 hours × 1 day/24 hours ×
$48,597.55
$2,784.96/POD per day × 20 PODs
Labor-salaries (total) + labor-training
Dispensing - Total Costs $1,811,210.75
(total) + security (total)
Inventory Management
Inventory Management - Labor
Inventory Management - Cost of Storage/Pallet
Inventory Management - # of Bottles/Pallet
Inventory Management - # of Pallets Required
Inventory Management - Storage (total)
Inventory Management - Total Costs (excluding
replenishment costs)
Inventory Management - Replenishment - Product
Purchase (overall)
Inventory Management - Replenishment -
Transportation (overall)
Inventory Management - Replenishment - Dispensing
(overall)
Inventory Management - Replenishment Costs
(total, SLEP)
Dispensing Time
Dispensing Time - SNS to RSS to Postal Office (source: CDC presentation)
13.24
Transportation (hours)
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POD Component Data Calculations
Costs
Dispensing Time - POD Operating Time (hours) 418,859.65 households/20 pods ×
20.94
1 hr/1,000 households
SNS to RSS to Postal Office
Dispensing Time - Total (hours) 34.18
Transportation + POD Operating Time
Total Costs - POD (56.18%, 955,000 doses/
individuals, 418,859.65 heads of household)
Product Purchase Price
Transportation
$0.00
Dispensing
$1,811,210.75
Inventory Management (without replenishment)
Total Cost (without replenishment) $3,345,180.35
Replenishment Costs (SLEP)
Total Costs - Postal Component + POD Component
Product Purchase Price
Transportation $0.00
Dispensing $4,146,340.35
Inventory Management
Total Cost (without replenishment) $6,919,617.69
$42,655.74
Replenishment Costs (annual)
Replenishment Costs (SLEP)
Replenishment Costs (annual + SLEP)
Total Dispensing Time for Strategy
313
continued
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TABLE D.1-6
314
Continued
POD Component Data Calculations
Costs
Dispensing Time for Postal Component (hours) 25.24
Dispensing Time for POD Component (hours) 34.18
Rate-Limiting Step (hours) 34.18
Total Dispensing Time for Strategy (hours) 34.18
OCR for page 315
Appendix D.2
Authors, Acknowledgments,
and Interviewees
AUTHORS AND ACKNOWLEDGMENTS
James Guyton is the lead author of this paper. The following PRTM
employees served as co-writers or contributors to this effort:
• Dr. Robert Kadlec
• Dr. Chandresh Harjivan
• Shabana Farooqi
• Sheana Cavitt
• Joseph Buccina
PRTM enjoyed the privilege of working with the Institute of Medi-
cine (IOM). PRTM would like to thank Clare Stroud, who served as an
immensely helpful point of contact. PRTM expresses its gratitude to the
Committee on Prepositioned Medical Countermeasures for the Public for
the opportunity to contribute to its mission. PRTM would also like to thank
Kristin Viswanathan for her assistance with the document review and all
IOM employees that contributed to this effort.
PRTM interviewed more than 40 subject matter experts on this topic.
The team would like to thank each of them for their time and their keen
insights.
315
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316 PREPOSITIONING ANTIBIOTICS FOR ANTHRAX
INTERVIEWEES
The following is a list of individuals who were interviewed by PRTM
for the purposes of this paper. Affiliations listed reflect the individual’s pri-
mary association as of the date of the interview.
Sid Baccam, Innovate Emergency Management, Inc.
Mike Berzig, Department of Veterans Affairs
Tara Blackley, Virginia Department of Health
Joseph Canzolino, Department of Veterans Affairs
Norm Coleman, Department of Health and Human Services (HHS),
Assistant Secretary for Preparedness and Response (ASPR), Office of
Policy and Planning (OPP)
Susan Cooper, Tennessee Department of Health
Victoria Davey, Department of Veterans Affairs
Adele Etheridge, Office of Public Health Preparedness and Response,
Centers for Disease Control and Prevention (CDC)
Matthew Feltman, Kroger/Giant
Sue Gorman, Office of Public Health Preparedness and Response, CDC
Jayne Griffith, Minnesota Department of Health
Roy Herman, Office of Public Health Preparedness and Response, CDC
Laura Herrera, Department of Veterans Affairs
Jack Herrmann, National Association of County and City Health
Officials (NACCHO)
Mary Beth Hill-Harmon, HHS/ASPR/Biomedical Advanced Research and
Development Authority (BARDA)
Jeffrey Holmes, PRTM
Nathaniel Hupert, CDC and Weill Medical College, Cornell University
Terrie Kolodziej, HHS/ASPR/BARDA
Lisa Koonin, CDC
George Korch, HHS/ASPR
Joe Larsen, HHS/ASPR/BARDA
Eva Lee, Georgia Tech University
Aggie Leitheiser, Minnesota Department of Health
Rebecca Lipsitz, HHS/ASPR
Rich McNally, HHS/ASPR
Carter Mecher, National Security Staff
Matthew Minson, Texas A&M University
Amanda Fuller Moore, North Carolina Department of Health and
Human Services
Stephen Morris, HHS/ASPR/BARDA
Chris Motsek, Office of Public Health Preparedness and Response, CDC
Paul Peterson, Tennessee Department of Health
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317
APPENDIX D
Jude Plessas, U.S. Postal Service
Ken Rapuano, The MITRE Corporation
Marjorie Sidebottom, University of Virginia
David Starr, Office of Emergency Preparedness and Response, New York
City Department of Health and Mental Hygiene
Jason Stear, Office of Public Health Preparedness and Response, CDC
Thomas Tighe, Direct Relief International
Penny Turnbull, Marriott Hotels International
James Turner, American College Health Association Representative,
Utility Services Provider
Michael Valentino, Department of Veterans Affairs
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