Bioterrorism and Other

Public Health Emergencies

Tools and Models for Planning and Preparedness

**Community-Based Mass Prophylaxis:**

**A Planning Guide for Public Health Preparedness**

**Prepared for:**

Agency for Healthcare Research and Quality

U.S. Department of Health and Human Services

540 Gaither Road

Rockville, MD 20805

[www.ahrq.gov](http://www.ahrq.gov/)

**Contract No. 290-02-0013-3**

# **Prepared by:**

Weill Medical College of Cornell University, Department of Public Health

Nathaniel Hupert, M.D., M.P.H.

Jason Cuomo, M.P.H.

Mark A. Callahan, M.D.

Alvin I. Mushlin, M.D., Sc.M.

Columbia University Mailman School of Public Health, Center for Public
Health Preparedness

Stephen S. Morse, Ph.D.

AHRQ Pub No. 04-0044

August 2004

This document is in the public domain and may be used and reprinted
without permission except those copyrighted materials noted, for which
further reproduction is prohibited without specific permission of
copyright holders.

**Suggested Citation:**

Hupert N, Cuomo J, Callahan MA, Mushlin AI, Morse SS. Community-Based
Mass Prophylaxis: A Planning Guide for Public Health Preparedness.
Prepared by Weill Medical College of Cornell University, Department of
Public Health under Contract No. 290-02-0013-3. AHRQ Pub No. 04-0044.
Rockville, MD: Agency for Healthcare Research and Quality. August 2004.

**Contents**

EXECUTIVE SUMMARY v

**Section One: Overview of Mass Prophylaxis**

1\. Mass Prophylaxis in Context 1

A. Components of outbreak response 1

B. Dispensing Operations and the Role of the Dispensing/Vaccination

Center (DVC) 2

2\. Overview of Planning For Mass Prophylaxis Using DVCs 5

A. Who are the stakeholders? 5

B. What resources are required? 9

C. Where will it take place? 10

D. When will it be needed? 12

E. How will it work? 12

**Section Two: Fundamentals of Dispensing/Vaccination Clinic Design**

3\. DVC Concept of Operations 15

A. Core functions 21

B. Support functions 23

4\. DVC Design and Patient Flow 19

A. Patient flow plans 19

B. Bottlenecks 23

C. Making things flow: the highway traffic analogy 24

D. Planning for breakdowns: what to do about lines (queues) 25

E. Additional factors affecting the efficiency of DVC operations 25

5\. DVC Calculations: Estimating Clinic and Staff Numbers 27

A. Number of DVCs 27

B. Number of staff 29

C. The Bioterrorism and Epidemic Outbreak Response Model (BERM) 30

**Section Three: From Principles to Practice: Examples of Antibiotic
Dispensing and Vaccination Clinic Plans**

6\. Example of an Antibiotic Dispensing Clinic Plan 33

A. Background 33

B. Design considerations 33

C. Model patient flow plan 34

7\. Example of a Vaccination Clinic Plan 37

A. Background 37

B. Design considerations 37

C. Model patient flow plan 38

D. Sample floor plan 42

**Section Four: Clinic Management/Command Structure**

8\. Overview of Mass Prophylaxis Command Structure 43

9\. DVC Command Structure 44

A. Core functions 44

B. Additional functions 48

C. Flexibility and redundancy 48

D. Command and control integration 49

References 51

Glossary 57

**Figures**

Figure 1: Elements of a local mass prophylaxis plan 5

Figure 2: Command structure of a mass prophylaxis campaign 14

Figure 3: Example of an antibiotic dispensing clinic plan 36

Figure 4: Example of a vaccination clinic plan 39

Figure 5: Sample vaccination clinic floor plan 42

Figure 6: DVC command integration 43

Figure 7: Model DVC command structure 45

**Appendixes**

Appendix A. Advisory Board 61

Appendix B. Thematic Bibliography 62

Appendix C. Technical Appendix: Modeling DVC Operations 68

Executive Summary

Recent intentional and natural disease outbreaks in the United States,
such as the 2001 anthrax attacks and the 2003 influenza season, have
focused increased attention on the ability of state and local public
health authorities to provide affected individuals and communities with
rapid, reliable access to prophylactic medications.^1-3^ In light of the
substantial health risks posed by anthrax, influenza, and other
bacteria, spores, toxins, or viruses, the U.S. Federal government has
called on all states to devise comprehensive mass prophylaxis plans to
ensure that civilian populations have timely access to necessary
antibiotics and/or vaccines in the event of future outbreaks.^4-6^

The last five years have seen a major expansion of Federal assets to
assist local public health providers in the planning and execution of
mass prophylaxis campaigns for bioterrorism and epidemic outbreak
response, including development of the Strategic National Stockpile
(SNS), improvement in public health laboratory capabilities, creation of
a national Health Alert Network (HAN), and implementation of the Cities
Readiness Initiative (CRI). ^5,\ 7,\ 8^ However, none of these assets is
intended to replace local first response capabilities or the need for
comprehensive local plans for extended mass prophylaxis campaigns in the
setting of a bioterrorist attack or natural disease outbreak.^9-13^

State, county, and local health authorities have been charged with the
development of these plans, with financial and technical support of the
Department of Health and Human Services Office of Public Health
Emergency Preparedness (OPHEP) as well as the Centers for Disease
Control and Prevention (CDC). This Planning Guide, which complements the
CDC's Strategic National Stockpile Guidebook (especially Chapter 11 on
dispensing operations), is intended to assist public health and
emergency management officials in this task.^5^

Section One of this Guide provides an overview of the five components of
a mass prophylaxis response to epidemic outbreaks: surveillance,
stockpiling, distribution, dispensing, and follow-up. The next two
sections focus on planning and conducting dispensing operations using
specially-designated dispensing clinics, here called
Dispensing/Vaccination Centers (DVCs) but also known as Points of
Dispensing (PODs). These concepts are then put to work in developing
sample antibiotic dispensing and vaccination clinic plans that can be
"run" using a separate customizable computer planning model, the
Bioterrorism and Epidemic Outbreak Response Model (BERM), developed in
conjunction with this planning guide. The last section describes the
implementation of a comprehensive operational structure for dispensing/
vaccination clinics based on the National Incident Management System
(NIMS).

This planning guide is intended for multiple audiences. Section One
should be of interest both to officials tasked with developing local
response plans and to members of government, industry, academia, the
media, and non-governmental organizations (NGOs) who may play important
roles in support of these emergency public health activities. Sections
Two and Three should be of interest to public health and emergency
management planners from the local to national level. Finally, the
description of the DVC command structure in Section Four demonstrates
the application of NIMS to this critical public health emergency
response role and may help non-public health emergency response
professionals successfully contribute to DVC operations and management.

**Section One: Overview of Mass Prophylaxis**

**1. Mass Prophylaxis in Context**

**A. Components of Outbreak Response**

Effective public health response to a bioterrorist attack or other
disease outbreak hinges on the ability to recognize the outbreak,
mobilize supplies of needed materials to affected populations in a
timely manner, and provide ongoing medical care for affected
individuals.^14,\ 15^ There are five distinct components of this
response:

1.  **Surveillance**

Surveillance activities may range from use of passive systems for
detecting specific pathogenic microbes in the environment to development
of syndromic surveillance programs to mine existing emergency medicine,
primary care, or pharmaceutical databases to rapidly identify unusual
clusters of suspicious symptoms.^16-19^ Determination of appropriate
trigger or action levels in these surveillance systems is an ongoing
challenge for medical and public health personnel that will not be
considered here.^20^

2.  **Supply and Stockpiling**

Response capacity to a large-scale bioterrorist attack may be limited by
the ready availability of antibiotics and/or vaccines.^21^ For this
reason, the Federal government has created the Strategic National
Stockpile (SNS), composed of a number of ready-to-deploy "Push Packs"
containing medical supplies to treat thousands of patients affected by
the highest-priority disease-causing agents (the CDC Category A agents),
as well as pre-designated pharmaceutical supply caches and production
arrangements that may be used for large-scale ongoing prophylaxis and/or
vaccination campaigns (Vendor Managed Inventory, VMI).^5,\ 22^ Some
large municipalities and medical facilities across the country also have
developed smaller stockpiles and secure supply chains for critical
antibiotics and medical materiel for use in terrorism response.^23-27^

**3. Distribution**

In the context of a mass prophylaxis response to bioterrorism,
distribution refers to the logistics of transporting materiel such as
antibiotics and vaccines from stockpile locations (e.g., the airhead
where the SNS has been deposited) to dispensing centers where they are
given to affected populations.^22^

**4. Dispensing**

Dispensing operations are the final step in getting prophylactic
medications and vaccines to affected populations.^28^ Dispensing center
functions (described more fully in Section Two) include mass triage,
medical evaluation of symptomatic individuals, pharmacotherapeutic
consultation for drug or dosage adjustment if needed, and provision of
antibiotics or vaccination.^29^ Additional functions may include data
collection, patient briefings, mental health or pharmacist
consultations, and emergency transportation for patients requiring
medical care.

**5. Followup**

Followup may include monitoring patients for antibiotic effectiveness or
vaccine immunoresponse, identifying patients who require dose
modification, and arranging alternative treatment for patients who have
adverse effects from the prophylactic treatment.^30^ As demonstrated
after the 2001 anthrax prophylaxis campaigns, follow-up data gathering
is also essential for determining compliance with recommended treatment
regimens.^31-33^

**B. Dispensing operations and the role of Dispensing/Vaccination
Centers (DVCs)**

Dispensing of antibiotics and/or vaccines is a cornerstone of any mass
prophylaxis campaign against outbreaks of preventable
disease.^12,\ 21,\ 34-43^ Without the ability to safely dispense large
volumes of medications or vaccines to community-based individuals,
efforts to improve surveillance, stockpiling, or distribution capacity
will not translate into improved public health response.^44^ Conversely,
dispensing operations are critically dependent on these surveillance,
stockpiling, and distribution functions for defining the prophylaxis
mission to be accomplished and for supplying the medical materiel
necessary for its successful completion.

There are two conceptual approaches to mass prophylaxis: "push" and
"pull". The "push" approach, exemplified by the recent Memorandum of
Agreement between the Department of Health and Human Services (DHHS) and
the U.S. Postal Service, consists of bringing medicine directly to
individuals or homes in an affected community.^45^ The "pull" approach,
in contrast, requires that individuals leave their homes or places of
work in order to travel to specially designated centers where they can
receive medications or vaccinations.^28,\ 39,\ 43^ Each approach has
strengths and weaknesses. The "push" approach may enable faster and more
widespread coverage of an affected community, but it has little
flexibility to handle medical evaluation for contraindications or dosage
adjustment and may be infeasible for vaccination campaigns.^31^ The
"pull" approach may increase efficient use of scarce health care
providers and resources, enable medical evaluation of potential victims,
and provide opportunities for centralized data collection and law
enforcement investigation (in the setting of a known or suspected
bioterrorism event).^46,\ 47^ However, these advantages must be weighed
against the delays and logistical challenges of setting up sufficient
dispensing centers to handle high patient volumes.^48,\ 49^

It is likely that in large-scale outbreak response, elements of both
"push" and "pull" strategies will be utilized. For example, in
addressing the needs of homebound or institutionalized individuals in a
community, a "push" approach may be preferred to avoid complex
transportation requirements in the midst of a public health crisis.
Alternatively, even if a "push" approach is used to provide the majority
of community residents with antibiotic prophylaxis, a small number of
dispensing centers may be established to handle specific sub-populations
(e.g., first responders and their families, tourists, etc.).^50^

As of this writing, "push" approaches to mass prophylaxis remain at an
early planning stage. For that reason, this planning guide will focus on
"pull" strategies using specialized dispensing centers. In local and
national planning documents, these centers have been given a variety of
names and acronyms. We use the term Dispensing/Vaccination Center (DVC),
though a competing (and perfectly acceptable) alternative name is Point
of Dispensing (POD).^5,\ 43^ We have chosen not to use POD due to
potential confusion with the term Point of Distribution, which refers to
the local or regional site for unloading and breaking down antibiotic
stockpiles shipped from the Strategic National Stockpile or other
sources (this is also called the Receipt, Store, and Stage (RSS) site).

In the "pull" model of mass prophylaxis, the Dispensing/Vaccination
Center is the principal operational unit of the dispensing function of
community-wide disease outbreak response.^40^ A DVC is a single
dispensing site that can be free-standing or located in a pre-existing
building such as a school. Any mass prophylaxis plan involving the use
of DVCs must have at least these two components:

-   A description of the command, operational, and logistical
    requirements for the deployment and operation of a single DVC

-   A description of the command, operational, and logistical
    requirements for a scalable response involving multiple DVCs to
    achieve timely community mass prophylaxis.

Factors such as the size and nature of the release of disease-causing
agents and the availability of local and Federal resources and personnel
will determine whether the initial response to a bioterrorist attack or
natural disease epidemic consists of the establishment of one, several,
or many dozen DVCs. The stockpiling and distribution components of a
public health emergency response plan need to be similarly scalable to
maintain a reliable and adequate supply of antibiotics, vaccines, and
other medical materiel to these DVCs.

CDC maintains the Strategic National Stockpile (SNS) and provides
technical assistance on dispensing operations to local public health and
emergency management planners throughout the United States. However, the
SNS and its support staff do **not** constitute a stand-alone first
response operation.^5^ Similarly, the National Disaster Medical System
(NDMS) has been established by the Department of Health and Human
Services to provide rapid response capability for medical disasters
throughout the United States, but this system as well is not designed to
supplant comprehensive local planning and operations for mass
prophylaxis campaigns.^51^

Instead, these Federal assets and resources are intended to build on the
local and regional first response infrastructure (that is, personnel and
planning, but [not]{.underline} necessarily stockpiles) for carrying out
mass prophylaxis. The basic rule of community-wide mass prophylaxis is:

There are at least four separate reasons underlying this rule:

-   Local mass prophylaxis activities (e.g., plan activation, DVC
    set-up, and possibly limited prophylaxis of select groups like
    hospital employees) will need to be underway prior to the arrival of
    any Federal assets.

-   Federal or state assistance is very unlikely to include sufficient
    personnel to fully command or staff community-wide mass prophylaxis
    dispensing operations.

-   DVC operation may likely remain under local control even after
    Federal and/or state assets are delivered.

-   Dispensing and follow-up operations may continue after the departure
    of Federal or state assets.

**2. Overview of Planning For Mass Prophylaxis Using DVCs**

The purpose of this Chapter is to survey the major issues that factor
into the creation of a successful mass prophylaxis plan. This
information will provide readers with a general understanding of the
complex issues involved in designing community-based dispensing
operations. It also serves as a primer for Sections Two and Three, which
are written for a more technical audience involved in development of
local DVC plans. Figure 1 shows an outline of this Chapter:

**Figure 1: Elements of a Local Mass Prophylaxis Plan**

![](media/image1.wmf)

**A. Who Are The Stakeholders?**

Many significant stakeholders should be included in planning for
civilian bioterrorism response.^9^ We focus here on the nine local
stake-holding groups who are essential to the planning and operation of
a mass prophylaxis plan in an emergency setting.

1.  **Population**

Planning starts with an understanding of the covered community.^52,\ 53^
Demographic, medical, and ethnographic information is critical to
developing DVC floor plans (e.g., taking into account accessibility
issues and typical family size), drug dosing schedules (e.g., age
distribution), and information dissemination activities (e.g.,
translation services for non-English-speaking populations). Population
density may be the chief determinant of choice of DVC sites (see Item C,
below). Since DVC operation would require population-wide cooperation
with directives to proceed to specific sites for triage and prophylaxis,
community representatives should be involved at the earliest planning
stages in order to increase the likelihood of community buy-in to DVC
plans (See Number 6, below). Prophylaxis for home- or institution-bound
individuals (e.g., nursing home residents, jail and prison inmates)
requires specific additional planning that is not covered in these
guidelines. The prophylaxis needs of these populations may be best
addressed through pre-existing delivery systems (e.g., U.S. Postal
Service, visiting nurse services, prison health systems) operating
within a "push"-style mass prophylaxis framework but separately from
community DVC activities.^45^

2.  **Public Health**

The Federal government is working collaboratively with state and local
public health officials to develop mass prophylaxis plans for
bioterrorism response.  The Strategic National Stockpile (SNS) Program
was developed to assist states and communities in responding to public
health emergencies.  The SNS Program ensures the availability of
medicines, antidotes, medical supplies, and medical equipment necessary
for states and communities to counter the effects of biological
pathogens and chemical nerve agents.  The SNS Program stands ready for
deployment and will arrive within twelve hours to any location across
the nation to augment medical resources, treat symptomatic individuals,
and provide prophylaxis therapy in support of efforts at the state and
local level.

The Centers for Disease Control and Prevention\'s (CDC\'s) cooperative
agreement on public health preparedness and response for bioterrorism
provides funding to upgrade state and local public health
jurisdictions\' preparedness for and response to bioterrorism, other
outbreaks of infectious disease, and other public health threats and
emergencies.  Funding through this cooperative agreement is also being
used to implement  the Cities Readiness Initiative (CRI), which will
help save lives through timely delivery of medicines and medical
supplies during a large-scale public health emergency.  Twenty cities
and the National Capital Region (District of Columbia) have been chosen
to participate in this pilot program. These cities have been chosen
based on their population and geographic location.

The CRI will provide direct assistance to cities to help them increase
their abilities to receive and dispense medicine and medical supplies
from the Strategic National Stockpile. As a result of this pilot
program, plans from all levels of government (federal, state and local)
will be unified to ensure a consistent, effective and timely response in
the event of a large-scale public health emergency. CRI will help ensure
that cities are able to use all the resources available to them for
emergency response and preparedness efficiently and effectively.

Continued collaborations between the federal government and local and
state public health officials are essential for developing mass
prophylaxis plans for bioterrorism response.  Public health
practitioners bring a diverse skill set to mass prophylaxis and DVC
planning, including expertise in epidemiology, health policy and law,
health and risk communication, and diagnosis and treatment of medical
and psychiatric disease.

3.  **Emergency Management**

Emergency management officials bring expertise in emergency response and
operational command structures to public health planning.^54^ They also
bring a broad perspective on incident management and have an
understanding of existing infrastructure and resources in the
community.^55^ In addition, these professionals may have experience in
directing interagency response operations.

4.  **Health Care Professionals**

Health care professionals, including nurses, pharmacists, emergency
service providers, and physicians, have detailed technical knowledge
that can inform planning at numerous stages along the prophylaxis
pathway (e.g., triage, materiel storage and packaging, medical
evaluation, drug dosing).^11,\ 56-58^ Additionally, since DVCs may be
intended to supplant normal health care venues in the setting of a
bioterrorist attack (at least initially during the prophylaxis stage),
an important aspect of DVC planning involves determining the optimal
role for community health professionals during the mass prophylaxis
response.^59^ If these professionals are expected to participate
directly in triage, evaluation, and dispensing activities, planning
should include development of educational material and in-service
training sessions directed at health care providers. Even if community
health professionals are not expected to have direct patient care
responsibilities in DVC operations, their cooperation is essential for
educating patients about mass prophylaxis, providing appropriate
directions to prophylaxis sites during an event, and providing follow-up
care after an attack.

5.  **Law Enforcement/Legal**

A bioterrorist attack would be both a public health emergency and a
crime, so law enforcement would have three distinct tasks in a mass
prophylaxis response: maintaining the safety and security of both
patients and medical stockpiles during the prophylaxis response,
maintaining public order generally, and carrying out a criminal
investigation of the attack.^46^ These three tasks may need to occur
simultaneously at each DVC, requiring extensive pre-planning and
coordination between law enforcement and public health authorities to
ensure proper resource allocation. Additionally, many aspects of DVC
planning and operation will involve legal issues that should be
carefully evaluated prior to any event (e.g., pharmaceutical dispensing
waivers, memoranda of understanding, emergency declarations, etc.).^60^

6.  **Community Relations**

Effective planning can make the public a valuable asset during disease
outbreak response.^61^ Mass prophylaxis would require the rapid and
coordinated mobilization not only of persons living in affected
communities but also of ancillary service staff (e.g., food preparation
and janitorial personnel) to support DVC activities. Community outreach
should:

-   Identify key non-media points of information dissemination in the
    community (e.g., community centers, civic clubs).

-   Assist emergency management professionals in creation of inventory
    lists of non-governmental resources that may be donated or lent in
    the event of an attack (e.g., volunteers, transportation vehicles,
    communication devices).

-   Educate the public about the general features of a mass prophylaxis
    response to natural or intentional outbreaks of disease.

-   Utilize the expertise and resources of established community-based
    organizations such as the American Red Cross.

7.  **Health Care System Representatives**

Traditional health care facilities such as hospitals and medical clinics
may not be optimal sites for DVC activities because of the need to
maximize space in these facilities for the treatment of mass
casualties.^55^ Nevertheless, each DVC must have direct communication
and transportation linkages with health care facilities capable of
evaluating and treating both severe attack-related illnesses and adverse
reactions to the antibiotics or vaccines administered in the
DVCs.^23,\ 62^ For that reason, representatives of local and regional
health care delivery systems (hospitals, multi-specialty clinics,
rehabilitation facilities, long-term care facilities) may provide
important assistance with certain aspects of mass prophylaxis planning
and should be included in the development of DVC plans.^63^
Additionally, communities may want to prioritize prophylaxis of hospital
staff and their family members in order to maintain maximum operating
capacity in the early days of an attack.^64^

8.  **Media Representatives**

Effective collaboration with local media is essential for community
preparedness.^65^ Harnessing multiple modalities for information
dissemination (e.g., radio, television, Internet) in the early hours of
a bioterrorist attack or other disease outbreak may greatly improve the
chances of effective community mobilization.^4^ This requires not only
close collaboration between public health and emergency management
officials and the media in the (pre-event) planning stages, but also the
creation of ready-to-air response scripts for immediate distribution to
media outlets.^53^

9.  **Liaison (interagency and inter-regional)**

Mass prophylaxis will constitute one of many response activities
initiated by local, regional, state, and Federal government agencies in
the setting of a bioterrorist attack or major disease outbreak.^66^
Interagency coordination in these activities will prevent unnecessary
duplication or unexpected absence of services (e.g., in transportation
and security details for DVCs), and inter-regional coordination will
minimize competing claims for scarce resources (e.g., for SNS materiel
in adjacent counties affected by an attack).^4,\ 67,\ 68^

**B. What Resources Are Required?**

Each DVC site requires, at minimum, the following:

**1. Supplies and Stockpiles**

Setting up and operating a DVC requires a range of generic office and
medical supplies in addition to specialized items like signage and
medications. Over the last year, several U.S. communities have developed
checklists and even pre-stocked trailers for rapid deployment of one or
multiple DVCs.

Once requested, assets from the Strategic National Stockpile are likely
to arrive in less time than it takes to set up a network of fully
functional DVCs. ^69^ Each DVC must have a well-defined supply route
linking it to the Receipt, Store, Stage (RSS) site for these SNS
materials as well as to any local stockpiles. Most local stockpiles are
pre-designated for use by local first responder, hospital, and emergency
management personnel to ensure that they are ready to work with the
public as soon as or before Federal assets arrive.

On-site stockpile management requires ability to ensure proper storage
(e.g., coolers), inventory management, and security of supplies. If the
DVC is dispensing antibiotics or vaccines under Investigational New Drug
(IND) protocols, local staff may have to track patients to whom those
supplies are distributed. However, recent legislative proposals call for
the creation of Emergency Use Authorizations to facilitate rapid
dispensing of "off-label" or investigational medicines and vaccines in
the setting of mass prophylaxis (e.g., Project BioShield, press release
at <http://www.whitehouse.gov/news/releases/2003/02/20030203.html>).

**2. Staff**

DVC staff fall into two categories: those engaged in direct patient
interaction (or "core staff") and those providing support functions.
(Details of the DVC core and support staff are covered in Section Two,
Part 3.B, while DVC command structure is covered in Section Four.) Core
staff may operate in one of three areas: medical (including triage,
medical evaluation, and emergency medical service (EMS)), psychiatric
(for acute and sub-acute evaluation and counseling), or
pharmacotherapeutic (for dispensing and evaluation of patients with drug
contraindications or other complicating factors). EMS staff may be
needed to stabilize seriously ill patients who are direct casualties of
an attack or outbreak, patients with exacerbations of chronic medical
conditions like asthma or cardiac disease, or patients who experience
severe adverse reactions to dispensed medicines or vaccines. These
patients may require transfer to health care facilities, as described in
Item 6, below. Support functions include DVC security, communications,
custodial services, and site management.

**3. Protocols**

All DVC activities should be protocol-driven to the greatest extent
possible to achieve maximum efficiency and standardization. At least
four protocols are needed for DVC operation: **triage**, **medical
evaluation**, **pharmacotherapeutic evaluation**, and **mental health
evaluation**.^29,\ 56,\ 70-72^ Of these, the first three may change
depending on the attack agent(s), with corresponding changes in
pharmacotherapeutic or vaccination response strategies. The last,
focusing on assessment and management of anxiety, grief, and panic
reactions, will be applicable to most, if not all, bioterrorism and
epidemic outbreak scenarios.

**4. Floor/Flow Plan**

The DVC plan should include a basic floor plan and description of
station-to-station patient flow under normal operation (e.g., precisely
how patients are supposed to proceed from triage to dispensing).
Optimally, all DVCs in a community should share the same basic layout,
thereby streamlining related agency planning activities (e.g., law
enforcement) and ensuring interoperability of staff between different
DVCs. This will simplify training and improve the operational
flexibility of staff. As detailed in Section Two of this guide, DVC
planners will need to design patient flow patterns to minimize
bottlenecks and optimize staff allocation.

**5. Support Services**

Since DVCs may be open 24 hours a day for many days in a row, planners
need to consider support services for staff including food preparation,
rest areas, toilet facilities, and counseling.^5^ Additionally, toilet
facilities should be identified for the public and staff both inside and
outside each DVC. Since clinic operation will likely include a variety
of minor medical procedures that may produce biohazardous waste (e.g.,
initiation of intravenous lines for patients requiring transport to
health care facilities), clinic services should include medical waste
disposal.

**6. Transportation**

Each DVC should have access to vehicles to transport casualties and
patients with acute illnesses identified through the DVC triage process
and for people who have immediate adverse reactions to the medications
or vaccinations administered in the DVC. Transportation capability for
transferring subacute patients to health care facilities (e.g., by
municipal bus) may minimize crowding at the DVC site.

**C. Where Will It Take Place?**

1.  **Location**

Choice of DVC sites should be guided by knowledge of local population
density and proposed location of stockpile staging and distribution
sites (called the Receipt, Store, and Stage (RSS) or Point of
Distribution (POD) sites). In the absence of complicating factors (e.g.,
environmental contamination preventing DVC set-up in a given locale),
DVCs should be situated so as to minimize transportation required for
both people and medical materiel. Ideally, these locations will be
familiar to local populations and can be rapidly demobilized and
returned to their original use after the event.^73^ Locations that may
have unintended stigma attached to them (e.g., STD treatment facilities)
or that have special cultural significance (e.g., religious
institutions) may pose challenges as sites for mass prophylaxis efforts.
Contingency (secondary or tertiary) sites should be identified in the
event of unavailability of primary sites.

**2. Size**

Optimal DVC size will vary, depending on a number of population-,
outbreak-, and staff-related factors (see Section Two for detailed
discussion of these factors and their impact on DVC design). To simplify
selection of DVC sites, planners may begin by cataloging all sites that
meet a set of requirements, such as a recognizable physical dimension
(e.g., area of a basketball court).^38^

**3. Security**

DVC sites should have both an outer and an inner perimeter that can
prevent wholesale movement of crowds into the dispensing area.
Additionally, the inner perimeter should have only a limited number of
controlled entry and exit portals. DVC sites also must have internal
storage and drug or vaccine preparation areas that can be secured during
clinic operational hours (See also Section Two, 3.B.8).

**4. Access**

DVCs should be accessible by forms of transportation that are common to
the community (e.g., automobile for rural and suburban settings, mass
transportation for urban settings). When scouting for potential DVC
sites, planners should consider handicapped accessibility issues to
provide coverage for people with impaired mobility.

**5. Storage**

DVC sites should have facilities for controlled storage of antibiotics
and vaccines, including electrical outlets for cold storage containers
requiring external power supplies.^5^ In addition, these sites should
have separate areas for storage of medical supplies, communication
equipment, and information dissemination material, which may require
different levels of security.

**6. Facilities support**

Proposed DVC locations should have space for safe removal and temporary
storage of medical waste, on-site potable water supply, electrical
wiring capable of supporting multiple electrical and electronic
appliances (e.g., coolers, computers), and restrooms. Food preparation
facilities are not necessary, but additional securable space for this
function is desirable in order to provide respite to staff.

In light of recent large-scale disruptions of electrical grids on both
the east and west coasts of the United States and the possibility that
future terrorist attacks may involve multiple (biological and
non-biological) threats, it is critical to ensure that proposed
dispensing sites have both backup power generation capacity and backup
fuel delivery arrangements for those generators. This applies especially
to DVCs that are intended for 24-hour operation.

**7. Communications**

DVC locations should have land-line phone capability to supplement
cellular, radio, and satellite communications, which may be unavailable
or overloaded during a terrorist event.^74^ Additionally, preexisting
video and audio equipment (e.g., school audio-visual equipment) may
reduce logistical burdens when planning staff training and public
briefings at the DVC sites.

**D. When Will It Be Needed?**

**1. Local triggers**

Local public health and emergency management officials may initiate the
rollout of full community-wide or more targeted mass prophylaxis plans
using DVCs in response to local triggers such as the isolation of an
unusual disease-causing organism in multiple patients (for example, in
an outbreak of meningococcal meningitis).^16,\ 19^ If SNS assets are not
requested, initiation of a local DVC plan does not require specific
state or Federal authorization. However, SNS requisition must follow the
chain of command established by CDC. Furthermore, any event involving
suspicion or confirmation of bioterrorism will trigger a Federal
criminal investigation.^4^

Local response capacity may be limited by the amount of local
pharmaceutical supplies (e.g., of prophylaxis caches for hospital staff
and their families in the setting of an infectious disease outbreak).

**2. Regional/Federal Activation**

Local DVC plans may be activated by regional, state, or Federal
authorities in response either to perceived threats to public health or
to actual release of pathogenic material.^75^ While activation may be
triggered at higher levels of government, DVC deployment and operation
will remain under local control. Local planners need to establish clear
procedures for confirmation of and response to such activations.

**E. How Will It Work?**

**1. Planning**

Mass prophylaxis planning involves the identification of stakeholders,
resources, sites, and triggers for DVC activation (items A-D above). DVC
planners are responsible for developing complete operational plans for
individual DVCs as well as plans to integrate multiple DVCs in a
large-scale response (See Figure 2). The full spectrum of activities to
achieve activation, maintenance, and demobilization of each DVC should
be addressed. It is important that plans have inherent flexibility to
adapt to unexpected changes in the unfolding events. Finally, these
plans should incorporate an incident command system which in turn should
be an extension of the community emergency management structure (for a
description of incident command systems, see Section Four).

2.  **Incident Command/Management**

DVC management and command structure should be addressed during the
early stages of planning. An effective DVC command structure should have
the following characteristics:

-   Pre-defined roles and responsibilities for all staff

-   Clear and uniform chain of command

-   Scalability to meet the needs of an increasingly or decreasingly
    resource-intensive prophylaxis campaign

-   Flexibility to respond to unanticipated variables

-   Integration into the community's emergency management system or
    Central Command and Control function (e.g., as spelled out in the
    National Incident Management System^74^)

The Incident Command System (ICS) and Incident Management System (IMS)
serve as widely-recognized and time-tested command systems upon which to
base DVC management.^74,\ 76^ Section Four of this guide presents a
detailed IC/MS-based management outline for DVC operation that addresses
these requirements.

3.  **Public Information**

To promote community buy-in of a mass prophylaxis campaign, the public
must be fully informed of the reasons for such a campaign as well as the
community's role in ensuring its success.^65,\ 77,\ 78^ The public
should be made aware of key procedures and responsibilities for
community bioterrorism response *prior to the initiation of a mass
prophylaxis campaign.*^79^ This may include publicizing the ways in
which the public would be assigned to DVCs (e.g., organized by zip code,
last name, etc.), the expected DVC processes (e.g., education followed
by prophylaxis), and post-DVC responsibilities (e.g., follow-up with a
local health provider). Local print, radio, television, and Internet
media representatives should be included in this planning process to
develop uniform public messages. Finally, training materials for DVC
staff and the general public should be developed early in the planning
process in order to minimize DVC operational start-up time in the event
of activation.

Many emergency management experts recommend [against]{.underline}
pre-publicizing the proposed locations of DVCs, since this information
may change prior to or during a mass prophylaxis event, thus
precipitating confusion. Emphasis instead should be placed on ensuring
that planners have robust means of communicating exact clinic locations
in an emergency setting.

**Figure 2: Schematic of the Command Structure of a Mass Prophylaxis
Campaign**

![](media/image2.wmf)

**Section Two: Fundamentals of Dispensing/ Vaccination Clinic Design**

Whenever possible, planners should develop a single generic DVC design
(including floor plan and patient flow plan) for use throughout their
community. Having a single master DVC plan will simplify training and
improve interoperability of staff, increase the ability to forecast
patient flow and therefore resupply needs, and maintain flexibility to
uniformly alter all DVCs in response to unfolding events.

DVC design may range from very simple to extremely complex, depending on
the nature of the event, requirements of the response, and time frame
for action. This Section covers general DVC functions, important factors
that affect the efficiency and accuracy of mass dispensing operations,
and methods for estimating patient flow through a single DVC and network
of DVCs. This planning guide may be used in conjunction with a
computer-based interactive spreadsheet model (the Bioterrorism and
Epidemic Outbreak Response Model, or BERM) that allows users to
calculate the number of personnel required to operate DVCs using either
an antibiotic dispensing or a vaccination design.^84^ The model allows
the user to study the relationship between various population- and
attack-related variables and DVC staffing requirements.

**3. DVC Concept of Operation**

DVC operations may be divided into **core** and **support** (or
"non-core") **functions**. Core functions include all processes that
directly facilitate the dispensing of drugs and vaccines and almost
always involve one-on-one interaction between staff and patients.
Exceptions include distribution of forms and patient briefings, in which
one staff member may interact with a large number of people at once.
**Core stations** are sites within the DVC where core functions take
place. Support functions include all the processes that take place in
the DVC that are critical in supporting the core stations. These tasks
range from medication or vaccine resupply to security to command and
control. Core and support staff are equally important to the overall
success of the DVC plan.

**A.** **Core Functions**

Core functions are also called "Operations" when using Incident
Management terminology.

1.  **Greeting**

Greeters have the dual role of directing people into the DVC and also
screening the crowd (visually and/or via direct questions) for obviously
ill patients who require immediate medical evaluation (i.e., skip steps
(b) and (c), below) or individuals at higher risk for exposure (i.e., if
time and location of exposure is known).

2.  **Form Distribution**

Most DVC plans will include some type of data collection using forms
filled out by patients.^40,\ 56,\ 71,\ 80^ These forms serve multiple
purposes, including guiding triage (e.g., by asking all those who
checked off a certain box or set of boxes to proceed to medical or
mental health evaluation) and facilitating follow-up (e.g., by asking
for contact information).

3.  **Triage**

Triage involves using patient-completed forms (see (b), above) or
protocol-based questions to identify people requiring medical evaluation
and/or, depending on DVC design, mental health
evaluation.^29,\ 70,\ 81,\ 82^ People who screen negative at triage can
proceed directly to the dispensing station. Since it is protocol driven,
triage does not necessarily need to be performed by health care
professionals.

4.  **Medical Evaluation**

Acutely symptomatic individuals or those who have symptoms suggestive of
illness due to the attack may require evaluation by health care
professionals, preferably staff who are experienced in evaluation and
stabilization of sick patients (e.g., paramedics and emergency
department nurses as well as physicians).^43^ Depending on time,
resource availability, and linkages to health care facilities, medical
treatment at DVCs may include initiation of antibiotics and other
interventions prior to transport for seriously ill patients.

5.  **Transportation Assistance**

Patients deemed seriously or critically ill will require assistance
getting into vehicles (e.g., ambulances, buses, vans) that can provide
transportation to tertiary care or other higher level care facilities.
The extent and complexity of potential DVC-based treatments for these
patients (e.g., whether to start intravenous antibiotics for a suspected
anthrax victim) will depend on the estimated time needed for transfer
from the DVC to the definitive care facility.^50^

6.  **Mental Health Evaluation**

If mental health activities are located in the DVC, they may vary from
simple evaluation and treatment of acute panic and stress reactions to
more extensive counseling for grief and depressive symptoms in the
aftermath of an attack.^72^ The type, extent, and proper location of
mental health evaluation in the DVC will vary based on details of the
disease outbreak, time frame for response, space, and availability of
trained mental health practitioners who can participate in DVC
activities.^83^ More elaborate DVC plans may call for separation of
acute and non-acute mental health stations.

7.  **Briefing**

Briefings may improve compliance with medical regimens, decrease mental
stress due to the event, and in some cases may be required by regulation
(e.g., with Investigational New Drug (IND) protocols).^5^ Additionally,
briefings may provide information about referrals to off-site
counseling. Briefings should take advantage of the standardization and
flexibility provided by pre-taped video/audio presentations, although
these require additional resources and technical support (e.g.,
translation into multiple languages). The size and number of briefing
rooms and the duration of briefings may limit the maximum rate of
patient flow through a DVC, as described below in Section 7.A.1.

8.  **Drug Triage (Pharmacotherapeutic Evaluation)**

The purpose of drug triage is to rapidly identify people who require any
drug regimen other than the standard drug type and dose (e.g., patients
requiring a medication other than adult dose doxycycline for anthrax
prophylaxis). Drug triage questions may be part of the written
information form filled out at entry to the DVC (see (b), above) or
asked of patients arriving in the dispensing area.^56,\ 71^ Families
with children may be identified at drug triage for further assistance to
determine pediatric dosages.

9.  **Dispensing or Vaccination (Express vs. Assisted)**

Patients may be directed to a single dispensing station that has staff
available for pharmacotherapeutic consultation or, alternatively, to one
of two dispensing areas designed to handle uncomplicated ("Express") or
complicated ("Assisted") dispensing cases. Large DVCs with sufficient
staff may achieve greater efficiency by establishing a separate
dispensing line for people whose drug triage evaluation suggests the
need for dose modification or an alternative drug. Assistance may
include determining the correct type and dose of antibiotics for adults
with reduced kidney function or medication allergies, or for children
based on age, weight, and/or height as well as history of allergic
reactions. Communities may opt to allow one person (e.g., the head of a
household, the spouse or friend of someone who has a mobility
impairment, etc.) to pick up medications for persons other than
themselves; these cases may take additional time and should be directed
to the "Assisted" dispensing area.

All DVC plans should include some mechanism for quality assurance, such
as designating a pharmacist or other health care professional to monitor
the accuracy with which antibiotics or vaccines are being dispensed.

10. **Form Collection and Exit**

Although patient information forms may have been used for triage
purposes inside the DVC, exit staff may still be needed to check the
accuracy of contact information as patients leave. Additionally, exit
staff may be able to provide details of follow-up care, reinforce
compliance messages, and even perform "spot check" for quality assurance
(e.g., checking whether patients are receiving the correct medications).

**B. Support Functions**

Support functions are also called "Logistics" when using Incident
Management terminology.

1.  **Drug/Vaccine Inventory, Preparation, and/or Re-supply**

CDC SNS supplies both unit-of-use antibiotic regimen bottles and bulk
supply of antibiotics and vaccines that can be repackaged at central
materiel distribution centers such as the Receipt, Store, and Stage
(RSS) site. Inventory support staff at each DVC will be responsible for
restocking dispensing stations with ready-to-use doses of antibiotics
and/or reconstituted vaccines. Re-supply staff should receive training
in cold-chain techniques and proper use of mobile cold storage devices
(e.g., Vaxicools).

2.  **Patient Traffic Directors**

DVC sites and entry points must be externally identified using
appropriate signage (e.g., using relevant languages in areas with
non-English speaking populations). Inside the DVCs, personnel are needed
to help direct patients from station to station and to assist in
managing crowds when bottlenecks form.^40^

3.  **Data Entry**

Data entry staff may be needed to transfer patient information from
written forms to computerized databases to facilitate epidemiological
investigation of the attack, assessment of the mass prophylaxis
campaign, and follow-up care for treated patients.

4.  **Translation services**

Planning for translation services includes ethnographic evaluation of
covered populations and identification of personnel who will be
available to provide appropriate translation services under crisis
conditions.

5.  **Communications/Information Technology Support**

Secure and reliable communication links inside each DVC, between
different DVCs in a given community, and from DVCs to a central Command
and Control center are critical to the successful implementation of any
DVC plan. In addition, key DVC operations including inventory management
and data entry may require computer support and secure Internet access
for web-based services.

6.  **Food Service**

Local factors will determine whether DVCs can support on-site food
preparation and/or distribution for staff. If not, planners will need to
find alternative means of providing meals, snacks, and beverages during
DVC activations.

7.  **Facilities Maintenance**

The need for facilities services will depend in part on the extent of
on-site food service and/or preparation, but extends to maintenance of
toilet facilities for both staff and patients, as well as facilities for
and staff trained in proper disposal of contaminated medical waste.

8.  **Security**

DVC security includes maintaining crowd control both outside and inside
the DVC as well as securing medication stocks, confidential patient
information, and communication and computer equipment inside the DVC.
Additionally, security staff is needed to ensure the personal safety of
DVC staff. While the past several years have seen increasing attention
by the public health community to these security needs for mass
prophylaxis campaigns, there is as yet no consensus on the number of
individuals required to achieve these goals. One approximation (derived
from live exercises at several U.S. sites with the SNS training package
(the "TED") is that for every four to five core staff assigned to the
DVC there should be approximately one security staff.

9.  **Managers**

DVC managers are considered support staff because they do not have
direct patient care responsibilities. However, the command staff may be
thought of as a separate work group. Section Four of these Guidelines
provides a description of a model command structure for DVC operations.

**4. DVC Design and Patient Flow**

This chapter reviews a number of possible clinic layouts (also called
patient flow diagrams) to help local DVC planners develop a DVC-based
mass prophylaxis plan that is appropriate for local needs, including
population size, staff resources, and response time frame.

**A. Patient Flow Plans**

One of the first tasks for mass prophylaxis planners is to determine
which core stations will be included in the basic DVC plan for their
community and what the physical arrangement of those stations will be in
each DVC. The choice of core stations for a given DVC design depends on
a number of factors, including the target patient flow rate (larger,
more complex station arrangements will inevitably lead to slower patient
throughput), the availability of personnel to adequately staff those
stations, and the physical space for DVC activities. The patient flow
diagrams shown below illustrate DVC designs of increasing complexity.
Note that while increasing complexity generally requires increased staff
and time, it does allow for valuable (and perhaps necessary) additional
processes, such as data collection.

**1. Diagram 1: Basic High Flow Model**

**Diagram 1**

![](media/image3.wmf)Very high patient flow rates would require
streamlining of many DVC functions in order to decrease the total
processing time of the average patient to the minimum needed to
accurately dispense medications and/or vaccines. The most basic
"high-flow" DVC design is pictured at right. It consists of only four
core stations (**triage**, **medical evaluation**, **transport
assistance**, and **drug dispensing**). Note that this DVC does not
include stations that may be required (e.g., briefings) or considered
useful given the nature of the event (e.g., distribution and collection
of data collection forms).

![](media/image4.wmf)**2. Diagram 2: High-Flow with Entry Screening
Diagram 2**

This diagram shows the addition of a **greeting and screening** station
to the basic four-component plan. This would facilitate rapid
identification and isolation of symptomatic patients in the setting of
an outbreak of a contagious illness or in the case of a rapidly fatal
disease such as anthrax. This floor plan was used to attain patient flow
rates of over 1,000 per hour in the high-flow antibiotic dispensing
exercise called Operation TriPOD in New York City (May 22, 2002).

![](media/image5.wmf)**3. Diagram 3: Form Distribution and Diagram 3**

**Collection**

This layout includes stations for **form distribution** prior to triage
and **form collection** directly prior to exit. In addition to allowing
data collection for epidemiological and medication follow-up purposes,
patient forms may be designed to facilitate triage and medical
evaluation. Forms with "check-off" boxes listing medical
contraindications and potential drug interactions may eliminate the need
for repetition at subsequent stations. Staff may annotate these forms as
a convenient way of communicating with other (downstream) DVC staff
regarding patient management (e.g., a patient who checks off a
potentially conflicting medication may have that box highlighted at
triage in order to let the specialists in the medical evaluation station
know why the patient had been sent over for further management).

**4. Diagram 4: Mental Health Evaluation Diagram 4**

![](media/image6.wmf)

This layout includes a **mental health evaluation** station located
after triage and before drug dispensing. Patients with acute and/or
debilitating symptoms of panic, fear, etc. in response to a large-scale
disease outbreak or bioterrorism event may not be in a position to
comprehend and follow even straightforward medical regimens. For this
subset of patients, mental health crisis counseling may improve their
ability to comprehend medical instructions and successfully utilize
prophylactic medications.

**5. Diagrams 5A and 5B: Briefing Diagram 5A**

![](media/image7.wmf)

Here, **patient briefing** is included as a separate station within the
DVC. Briefings may be mandated (e.g., in settings where informed consent
is required for administration of an investigational drug) or deemed
useful for improving patient adherence to medication regimens and/or for
calming fears about a bioterrorist event.

Briefing stations may be situated before or after triage, depending on a
variety of factors such as the importance of rapidly identifying
patients with symptoms suggestive of attack-related illness. If briefing
is mandatory and the likelihood of symptomatic disease is low (e.g., in
a pre-event mass vaccination campaign for smallpox), then the briefing
station should be situated to capture a large proportion of patient flow
(Diagram 5A). Conversely, if early detection is a priority **Diagram
5B** ![](media/image8.wmf)(e.g., as with inhalational anthrax, where
on-site treatment of suspected cases may involve rapid administration of
antibiotics),

then briefing should be limited to patients who are asymptomatic or
those whose symptoms have been fully evaluated and deemed not to require
immediate intervention beyond routine prophylaxis (Diagram 5B).

**6. Diagrams 6A and 6B: Express Dispensing Diagram 6A**

![](media/image9.wmf)

The 2001 Capital region response to the anthrax attacks validated the
notion of creating a **separate drug triage area** and "**express
drug**" line to facilitate rapid dispensing of antibiotics to
asymptomatic persons with no drug contraindications.^56,\ 71^ The
justification for adding this additional step to overall patient flow is
that pre-identification of complicated cases (i.e., those requiring
consultation with a pharmacist or physician prior to receiving
medication) will speed overall processing time in the dispensing area by
not clogging all dispensing points with potentially long delays. This
will allow better utilization of specialist staff at designated
"assisted drug dispensing" areas.

Diagrams 6A and 6B show that these changes in drug dispensing operations
are compatible with both DVC plans covered in **Diagram 6B** Diagram 5.
Drug triage may be facilitated by ![](media/image10.wmf)appropriately
designed forms that allow easy identification of adult and pediatric
patients whose age, medical conditions, or preexisting

medications necessitate dose or drug adjustment. For example, check
boxes may be aligned on the form to highlight positive responses upon
quick (i.e., less than 10 second) visual scanning.

**7. Summary of Patient Flow Diagrams**

These plans show patient flow paths through a variety of DVC designs and
illustrate the potential complexity and variability of DVC station
layouts. While such plans may be adopted "as is," they are intended to
serve more as a starting point for local planning than as final designs.

**B. Bottlenecks**

In order to minimize bottlenecks in patient flow, a DVC should be
designed with a floor plan that prioritizes the expected transit pattern
of the following three patient groups:

-   **Uncomplicated cases**: individuals who are asymptomatic and/or
    unexposed (e.g., in the case of smallpox) and have no pre-existing
    conditions requiring specialized dispensing/prophylaxis regimens

-   **Specialized-care cases**: individuals with mild, non-outbreak
    related symptoms and/or pre-existing conditions or possible
    contraindications requiring specialized dispensing

-   **Seriously ill individuals:** identified upon entry, at triage, or
    at medical evaluation with disabling and/or life-threatening
    symptoms needing immediate medical attention and transportation to a
    health care facility

Since the majority of patients will most likely fall into the first
group, even small errors in DVC layout for this group may adversely
impact overall patient flow rate. In this case, a small delay may not
necessarily affect outcomes for the individual patient, but it may
affect the operating efficiency of the mass prophylaxis campaign as a
whole. Specialized-care cases will constitute a smaller group but
require increased time and/or resources. Small, infrequent delays will
have less of an effect on DVC operating efficiency, but a constant delay
eventually will lead to the formation of bottlenecks and may adversely
affect clinic operations. Seriously ill individuals will constitute a
small minority of patients processed by the DVC in all but the most dire
of scenarios. Consequently, design flaws in medical evaluation and
emergency transportation areas will not significantly affect overall DVC
operating efficiency. However, these delays may adversely affect the
care of individual patients. Ideally, the routing of patients from entry
to exit should be as direct as possible for all three groups, with
seriously ill individuals traveling the shortest distance from entry to
transport.

**C. Making Things Flow: The Highway Traffic Analogy**

Highway automobile traffic provides a useful analogy for understanding
the factors that can interfere with efficient patient flow in the DVC.
There are four basic causes of traffic jams: **merges** (e.g., of two
lanes into one), **surges** (e.g., rush hour), **accidents** (which can
block both the affected lane and adjacent ones due to spectators), and
**tolls** or other features of the road that slow the speed of all cars
(e.g., bridges).

**Merges** are easily managed at the DVC design stage: DVC stations and
staffing should be arranged to avoid line merges, especially in areas
seeing the majority of patient flow, since these will lead to backups
and queues that may interfere with DVC support functions (e.g.,
re-supply). Backups due to **surges** in arrivals are more difficult to
solve at the DVC design stage, since these may require shifting or
adding staff or shortening processing times (e.g., shortening patient
information briefings or forms) to handle increased patient flow. DVCs
that are designed to process a certain patient volume without
bottlenecks should therefore have a staff member assigned to monitor and
report incoming patient flow in order to expedite these types of
adjustments before DVC operations are affected by any sustained surge.

The DVC equivalent of a **traffic accident** could be a patient who is
seriously ill on arrival and requires immediate assistance at the
entrance to the DVC (thus blocking traffic) or any person or group who
requires special assistance (e.g., a large family, a disruptive
individual, etc.). Contingency plans to manage these and other
unexpected events should be developed with the goal of identifying DVC
locations and staff to isolate the affected individual(s) from the main
flow of patients in order to minimize bottlenecks that compromise
overall DVC efficiency.

The DVC analogy to the **toll booth** is the core station (e.g., triage,
drug dispensing) that requires a certain processing time for each
patient. The length of this processing "delay" will be determined by the
length of the protocols and forms and by the waiting time at each
station; for patient information stations, this delay is determined by
the duration of briefings plus any question and answer period. Designers
of briefing scripts and station protocols need to balance thoroughness
with efficiency and economy in order to maintain smooth patient flow.
Ideally, planners should also pre-designate ways in which these
processes can be shortened if bottlenecks do occur and lines begin to
form (e.g., pre-identifying portions of a briefing that can be
eliminated or provided by alternate communications modalities like radio
or television).

**D. Planning For Breakdowns: What to Do About Lines (Queues)?**

Lines (technically called "queues") may form inside the DVC whenever the
arrival rate exceeds the processing rate. In general, this may result
from a "surge" in new arrivals (i.e., above the baseline for which staff
has been allocated), from a decrease in staff below what is needed to
process the baseline arrival rate, or from an increase in the time
needed to process individuals in the DVC. This is so important and
seemingly obvious that it bears repeating: bottlenecks and their
resultant queues arise, in general, from only three causes:

-   Too many patients

-   Too few staff

-   Too much to do.

DVC floor plans should take into account the possibility that queues
will form at each station as part of the natural variation in arrivals,
staffing, and processing times. The amount of space allocated for these
queues cannot be accurately predicted prior to running of the DVC. One
general rule of thumb is that for two stations with identical arrival
rates but different processing times (and therefore different numbers of
staff assigned for baseline operation), the removal of a staff member at
the *quicker* station will lead to more rapid development of a queue
than removal of a staff member at the *slower* station.

The reason for this is that each staff member at the quick station
processes more individual patients per unit time than staff at the slow
station. Thus the relative loss of each additional staff member from the
quick station will have a greater impact on maximum queue size (though
not necessarily on queue duration, if the problem is rectified by
addition of a staff member to the station) than from a slow station. *In
short, staff reductions at quick stations have the potential to produce
large (though potentially short-lived) queues, while staff reductions at
slow stations may produce smaller queues of longer duration.*

**E. Additional Factors Affecting the Efficiency Of DVC Operations**

Several factors in addition to the design of the DVC floor plan and
station placement may also affect the efficiency of DVC operations.
These include:

1.  **Accessibility**

Families are an important and often overlooked group with unique
accessibility issues from the standpoint of DVC design, since they will
likely travel as a single large group. Therefore, DVC layouts should be
flexibly configured to accommodate both individuals and large family
groups as the "patient." Plans that incorporate inaccessible locations
or transit routes (e.g., DVCs placed at sites with stairs or other
features that restrict movement of people with assistive mobility
devices) may require additional personnel to provide assistance to
affected individuals.

2.  **Translation services**

Lack of adequate translators may seriously impede processing of
non-English speaking patients and therefore cause bottlenecks that may
slow overall DVC operations. Communities with limited personnel for
translation may want to pre-print or pre-record material for specific
response scenarios in appropriate languages.

3.  **Dispute resolution**

DVC policies regarding triage and dispensing may lead to disagreements
between staff and patients. In order to prevent these disagreements from
causing bottlenecks at the station where they occur, DVC planners should
designate a specific location within the DVC and an operational protocol
for mitigating anticipated disputes (e.g., establishing guidelines
governing whether a single individual can be given medications for
multiple other individuals).

4.  **Geography**

Population density and geographic location may influence the development
and implementation of prophylaxis plans. For example, finding
appropriate locations for DVC operations in rural areas requires
consideration of unique transportation, resupply, and communication
issues compared to those encountered in urban settings.

**5. DVC Calculations: Estimating Clinic and Staff Numbers**

The following section presents an overview of one method for calculating
the number of DVCs necessary for a mass prophylaxis campaign and the
number of staff needed to operate a given DVC. Planners interested in
the mathematical details behind this approach and in performing more
detailed calculations are referred to the accompanying computer model,
the Bioterrorism and Epidemic Outbreak Response Model (BERM) and its
technical appendix (which is reproduced as an appendix to this report).

**A. Number of DVCs**

Planners can determine how many DVCs they will use for a mass
prophylaxis campaign in one of three ways:

1.  By determining the **total number of sites available** in their
    community. This would require fitting all necessary DVC activities
    into those pre-selected sites. An example of this was the 1995
    Minnesota meningococcal meningitis vaccination campaign that took
    place at a single site with approximately 300 staff.^36^

> **Advantage**: Fits the mass prophylaxis plan to existing community
> structures
>
> **Disadvantage**: May result in mismatch between sites and
> population/available staff size

2.  By determining the **total number of staff needed to operate a
    clinic** (e.g., deciding that, for security or other reasons, each
    DVC should have no more than 100 core staff operating at a given
    time). Dividing the total staff required for a prophylaxis campaign
    (determined using the BERM model) by the per-DVC staff size gives
    the number of DVCs that should be established.

> **Advantage**: Ease of planning (one size fits all)
>
> **Disadvantage**: Requires estimate of total staff needed for campaign

3.  By estimating the **maximum number of patients that could be
    processed** at a standard DVC (that is, the patient flow rate).
    These estimates can be derived from a number of sources: nationally
    publicized exercises (e.g., ranging from roughly 200 patients per
    hour for a single smallpox vaccination clinic (San Francisco, 2003)
    to up to 1,200 patients per hour for a single high-flow anthrax
    antibiotic dispensing clinic (New York City, 2002)); from previous
    local experience with influenza vaccination and other public health
    clinics; or from calculations based on the duration of patient
    briefings at the proposed DVCs, as described below. The number of
    DVCs needed is then calculated by dividing the community-wide
    patient flow rate (which is just the number of patients needing
    prophylaxis or vaccination divided by the number of days or hours
    allotted for the campaign) by the per-clinic patient flow rate.

> **Advantage**: Fits the mass prophylaxis plan to population size and
> response time
>
> **Disadvantage**: May be difficult to estimate per-DVC patient
> processing rate

The following scenario illustrates this last method using the length of
briefings to determine DVC flow rate, and therefore overall number of
DVCs:

1\. Calculating per-DVC patient processing rate:

City A has a population of one million residents, all of whom require
prophylaxis in 6 days or less using DVCs that have mandatory briefings
for all patients. Planners have decided that each DVC in City A will
have three briefing areas capable of handling 50 patients apiece and
that each briefing (with a question and answer period) will take 20
minutes. Since these briefings are mandatory, they represent the
**critical rate-determining step** for patient flow: assuming that there
are sufficient patients to fill every briefing, each DVC will have a
**maximum** patient flow rate of

3 briefing rooms x

50 patients per briefing x

20min per briefing =a 3 briefings per room per hour

= 450 patients per hour, or 8 patients per minute.

This means that for the proposed DVC to process patients without
bottlenecks, it must be designed to handle 8 patients per minute from
entry to exit. If not, then either briefings will go unfilled (because
patients cannot get to them) or stations downstream from the briefings
will be overwhelmed and will back up (when patients emerge from the
briefing rooms).

The reader can create a basic spreadsheet model to calculate the maximum
patient flow rate for any DVC that has mandatory briefings. This model
lets you see the effects of varying the number of briefing rooms, the
number of patients per briefing, and the time needed for each briefing.

Using any standard spreadsheet program, create the following fields:

  ------------------------------- ---------------- -----------------------
  NAME                            FORMULA          EXAMPLE

  Number of briefing rooms        =A               e.g., 3

  Number of patients/briefing     =B               e.g., 50

  Duration of each briefing       =C               e.g., 20 minutes
  (minutes)                                        

  Maximum patient flow per clinic =(AxB)C=D        e.g., 7.5 patients per
  given these parameters (per                      minute
  minute)                                          

  Maximum patient flow per clinic =(AxBx60)C=E     e.g., 450 patients per
  given these parameters (per                      hour
  hour)                                            
  ------------------------------- ---------------- -----------------------

For comparison, recent vaccination campaigns against meningococcal
meningitis in Alberta, Canada and Minnesota achieved processing times of
between 2.7 and 13 patients per minute per DVC.^85,\ 86^

2\. Calculating community-wide flow rate:

Next, the rate of prophylaxis for the entire population must be
calculated. For City A, the overall rate of prophylaxis for the entire
population is one million divided by the six days available for
treatment, or 116 patients per minute. If each DVC can process 8
patients per minute (calculated above), then 14 DVCs are needed to
provide prophylaxis to the entire community in the allotted time
(assuming 24-hour operation of each DVC). In contrast, if DVC processing
is limited to only 2.7 patients per minute (as was seen in the Alberta,
Canada meningitis vaccination campaign), then 43 DVCs are needed to
carry out community-wide prophylaxis in the specified time frame of six
days. To model these calculations, the reader may continue to build the
spreadsheet as follows:

+--------------------------------+-------------+----------------------+
| NAME                           | FORMULA     | EXAMPLE              |
+--------------------------------+-------------+----------------------+
| Population size                | =F          | e.g., 1,000,000      |
+--------------------------------+-------------+----------------------+
| Number of days for prophylaxis | =G          | e.g., 3              |
+--------------------------------+-------------+----------------------+
| Community-wide patient flow    | =FG2460=H   | e.g., 231 patients   |
| rate (patients per minute)     |             | per minute           |
+--------------------------------+-------------+----------------------+
| Community-wide patient flow    | =FG24=I     | e.g., 13,889         |
| rate (per hour)                |             | patients per hour    |
+--------------------------------+-------------+----------------------+
| Number of clinics required to  | =HD         | e.g., 30.8, which    |
| achieve prophylaxis goal in    |             | rounds up to 31      |
| allotted time                  | or = IE     | clinics              |
+--------------------------------+-------------+----------------------+

The estimated number of DVCs required to complete a prophylaxis campaign
is one of the most critical calculations in all of mass prophylaxis
planning. There are considerable logistical differences in setting up,
staffing, and running a handful compared to several dozen DVCs. Every
local DVC planning team should attempt to determine the number of DVCs
required for community-wide prophylaxis under different response
scenarios.

**B. Number of Staff**

One of the most difficult features of DVC planning is determining how
many staff would be needed to work at a given station within a DVC. The
accompanying Bioterrorism and Epidemic Outbreak Response Model (BERM)
allows calculations of the number of staff needed to carry out a
prophylaxis campaign using two different pre-specified DVC designs, one
for antibiotic dispensing and another for vaccination.^84^ The
calculations underlying these estimates are described in detail in the
model's Technical Appendix, but deserve comment here as well. The main
concept underlying these calculations is the notion that every DVC
should be capable of what is called "steady-state operation." This means
that every clinic should be capable of operating at full capacity
without developing progressively larger bottlenecks, which would show up
as queues. In other words, the operational goal of any DVC should be
that, at minimum, it does not continuously back up to the point of
complete shutdown. A DVC operating at this "steady-state" has achieved a
balance between the number of staff, the number of patients, and the
time needed for those staff to process those patients such that there is
no increase in bottlenecks or queues. While this may never actually
occur during real-life operations (due to a variety of factors such as
unpredictable surge arrivals, etc.), all DVCs should, at a minimum, be
designed to achieve steady-state operation.

Fortunately, it is possible to calculate the number of staff needed to
run a system that is operating in a steady-state manner. These
calculations can provide planners with two important sets of data:
either estimates of the [minimum]{.underline} number of staff needed to
process patients at a given rate of arrival and for a given processing
time, or estimates of the [maximum]{.underline} processing time
permitted for a given number of staff to process patients at a given
rate of arrival. The next section is a summary of the Technical Appendix
of the BERM model for readers interested in how these calculations are
carried out.

**C. The Bioterrorism and Epidemic Outbreak Response Model (BERM)**

The BERM model was created by researchers at Weill Medical College of
Cornell University in 2003 under contract to the Department of Health
and Human Services, Agency for Healthcare Research and Quality
(AHRQ).^84,\ 87^ In contrast to previous spreadsheet models of
bioterrorism response that have focused on resources needed for a
military medical response, this model is designed for civilian response
to bioterrorism and epidemic outbreaks requiring mass prophylaxis.^88^
Its goal is to assist public health and emergency management planners to
create customized community mass prophylaxis plans using a DVC-based
dispensing approach.

Model inputs include community population size, time frame for response,
characteristics of DVC operations (e.g., hours of operation, number of
shifts, rest-time for workers), rate of patient processing at each DVC
(calculated using one of the three methods described above) type of
operation (pill dispensing or vaccination), operational setting (e.g.,
pre-event in which only a small proportion of patients will need medical
attention vs. large-scale event in which up to 20% of patients will be
symptomatic on arrival to the DVC), and DVC processing speed (baseline,
slow, or fast). Depending on the type of operation chosen, the model
runs off one of two generic DVC layouts of either an antibiotic
dispensing clinic (similar to those set up in Washington, D.C. after the
2001 anthrax attacks) or a vaccination clinic (similar to the CDC
smallpox vaccination model, but modified by the Weill/Cornell
researchers). These clinic layouts represent a composite of several
published plans, including those of the CDC, U.S. Public Health Service,
Central Florida Regional Domestic Security Task Force, and the
California Emergency Medical Services Authority.^80,\ 89-91^ Each layout
defines the number and type of stations where **core staff** are needed.
Additionally, users can customize the model by inputting the number and
type of **support staff** needed for operation of a single DVC.

Once this information is entered into the model, it calculates what is
needed for operating a multi-DVC-based, community-wide mass prophylaxis
in the specified time frame. Specifically, it gives estimates of the
number of DVCs needed to treat the entire community as well as the
number and type of core and support staff at each DVC, for each shift,
and for the entire prophylaxis operation. If the model results indicate
that more staff are needed than are available in the community, then
users can easily re-calculate how long it would take to cover the entire
population using the actual number of staff on hand.

The ultimate purpose of the BERM is to allow planners to "think with
numbers" as they go about formulating realistic mass antibiotic
dispensing and vaccination contingency plans for their target
populations. Using a model that provides numerical estimates forces
critical examination of assumptions about prophylaxis clinic design and
about the availability of human and materiel resources. Estimates
derived from this model should be viewed as one type of data among many
that may be useful for planning (other data might include previous local
experience with immunization campaigns, or results of training exercises
for bioterrorism response).

As with any model, the accuracy of the numerical estimates provided by
this program depends on the quality of the underlying data on which they
are based. For example, the station-specific processing time estimates
used in this model have a large impact on outcomes (to demonstrate this,
observe the change in overall staffing estimates for a given scenario
under slow, baseline, and fast processing times). In order to improve
ease-of-use, the model provides these three pre-set choices for
processing times and three pre-set choices for disease prevalence
(pre-event, small-scale event, or large-scale event). The trade-off here
is with "realism" of the outputs, since real-world events rarely conform
to such neat categories. However, examining how community-wide
prophylaxis plans would need to adapt to these nine (3 x 3) scenarios
may go a long way to exposing heretofore unidentified stresses on
prophylaxis plans already in place or under development. (Additionally,
for those who are interested in finer-grained customization of BERM
outputs, the model includes a separate page for altering and customizing
every element of these baseline scenarios.)

###   {#section .unnumbered}

### Section Three: From Principles to Practice: Examples of Antibiotic Dispensing and Vaccination Clinic Plans

Since the 2001 U.S. anthrax attacks, a number of scientific studies have
underscored the importance of rapid mass prophylaxis of civilian
populations to prevent casualties in real-life and hypothetical disease
outbreak scenarios.^37,\ 43,\ 92-94^ This Section suggests ways to use
some of the design principles introduced in the last Section to develop
efficient patient flow plans for mass prophylaxis clinics. Following the
BERM model, it includes examples of both antibiotic dispensing clinics
(e.g., for prophylaxis against inhalational anthrax) and vaccination
clinics (e.g., for pre- or post-event vaccination against smallpox).

**6. Example of an Antibiotic Dispensing Clinic Plan**

**A. Background**

Mass antibiotic prophylaxis would be needed for outbreaks of disease due
to any of the three bacterial pathogens on the CDC list of "Category A"
agents posing the maximum risk to public health and welfare: anthrax,
plague, or tularemia.^6^ Anthrax, for example, is a spore-forming
bacterium that can infect humans via inhalation, direct contact, or
ingestion, and is highly lethal if untreated.^17^ The 2001 experience
with inhalational anthrax suggests that approximately half of those
presenting with fulminant inhalational anthrax may die despite advanced
medical care. However, there is considerable evidence that use of
prophylactic antibiotics may prevent the development of fatal anthrax
even in patients who have inhaled an infectious dose of anthrax spores
and who have early symptoms of the disease, such as fever, cough, severe
headache, nausea, and chest discomfort.^32,\ 37^

While scientific uncertainty remains about the average duration of the
asymptomatic incubation period in patients exposed to anthrax, the 2001
U.S. experience suggests that in a number of cases there was ample time
and opportunity for initiation of prophylactic antibiotics after
exposure.^1^ Over the past five years, the Federal government has
overseen the purchase and stockpiling of a number of antibiotics that
may be effective in prophylaxis against inhalational anthrax as well as
against plague and tularemia. These medications, which are managed and
delivered by Strategic National Stockpile (SNS), were used in the
Florida, New York/New Jersey, and National Capital Region anthrax
response.^40-43,\ 56,\ 71^

**B. Design Considerations**

An antibiotic dispensing clinic suited to anthrax post-exposure
prophylaxis (or pill-based prophylaxis for other biological pathogens)
would need to accomplish a limited number of goals, the most important
of which is getting the correct antibiotic to the correct patient in the
shortest amount of time. Since patient compliance with prescribed
medication regimens and side effects from those medications proved to be
an unexpectedly important factor in the 2001 U.S. anthrax response, an
additional goal would be to provide educational material and the
opportunity for patients to ask questions of emergency health care
providers. ^31-^^33^ To assist in epidemiological investigations,
patient follow-up, and resource management for the mass prophylaxis
response, a further goal of the clinic design would be to allow for the
documentation of patient-related information either through written
forms or through question and answer sessions with clinic staff.^40^
Clinic planners may want to include a separate area for on-site crisis
counseling to help manage individuals who are incapacitated by stress or
anxiety.^78^ Finally, each clinic should have a designated area for
triage and management of acutely ill individuals who require emergency
transfer out of the dispensing clinic to a health care facility.

For bacterial agents that pose the risk of patient-to-patient spread
(e.g., pneumonic plague), an additional goal would be to separate any
symptomatic individuals from the asymptomatic populace as soon as they
reach the clinic. In this setting, application of appropriate
respiratory precautions (e.g., by giving symptomatic individuals
OSHA-rated N-95 masks or the equivalent immediately upon identification)
may minimize the risk of intra-clinic spread of disease. While it is
always preferable to prevent infection when possible, it should be noted
that even if a patient were to become infected with a contagious disease
inside the dispensing clinic, the chance of that infection progressing
to actual symptomatic illness should be greatly diminished by the use of
prophylactic medications.

**C. Model Patient Flow Plan**

These design considerations led to the antibiotic dispensing clinic flow
plan shown below (Figure 3), which was highly influenced by the
published reports of Montello and Haffer regarding the design and
operation of the dispensing clinics used for the 2001 National Capital
Region anthrax response.^56,\ 71^ Patients are greeted immediately
inside the clinic by a staff member whose sole purpose is to identify
anyone who is acutely ill in order to send them immediately for medical
evaluation. In the case of a contagious disease, the staff member would
also supply the affected individual with a mask at this time. The
remaining patients would be given forms to fill out; it is preferable to
give out forms prior to any briefing, since the individuals performing
the briefing may want to refer to information or questions on the forms.

The next step is the first triage station. Triage may be accomplished by
reading the patient's form (e.g., by visually scanning checkboxes for
questions about symptoms) or may be accomplished through a limited
series of questions. This general triage step seeks to identify patients
who have symptoms that warrant either medical or psychological
evaluation and/or management. Patients who screen positive at this stage
are sent either to the medical evaluation or to crisis counseling
stations. All others proceed to the briefing area, where they may be
joined by individuals returning from those two stations (i.e.,
individuals whose symptoms or concerns were evaluated and addressed by
health care professionals and whose condition was deemed stable enough
to warrant return to the main clinic).

From the briefing, patients proceed to drug triage, where patients
needing special assistance with drug prescribing (e.g., alternative drug
regimens, dosage adjustment) are identified and sent to a designated
dispensing area where pharmacists or other trained health professionals
can tailor the dispensed regimen to a patient's individual medical
requirements (e.g., due to other medical conditions or age, height, or
weight considerations). All other patients proceed to an "express"
dispensing area where no further decisions regarding type or quantity of
medication are necessary. Splitting dispensing this way increased
efficiency in the 2001 anthrax response. ^56,\ 71^ After receiving their
antibiotics, patients may deposit their forms and exit.

**Figure 3: Example of an Antibiotic Dispensing Clinic Plan**

![](media/image11.wmf)

**7. Example of a Vaccination Clinic Plan**

**A. Background**

Both smallpox and the viral hemorrhagic fever (VHF) viruses are
classified by the CDC as "Category A" biological agents posing the
maximum risk to public health and welfare.^6^ At the time of this
writing, a well-tested, highly effective, and widely available vaccine
exists only for smallpox, although considerable scientific effort is
being devoted to developing countermeasures for VHFs. Smallpox infection
carries a 30% mortality rate in unvaccinated individuals; in previously
vaccinated individuals who develop the disease (e.g., in whom immunity
has waned years after vaccination), the mortality rate drops to
3%.^95,\ 96^ U.S. residents under the age of 30 have virtually no
immunity to the disease, and older adults likely have little remaining
immunity since immunizations and booster shots for the general public
were halted in 1971.^97^

Despite its high mortality and morbidity, smallpox has two features that
should give a measure of optimism to public health officials planning a
mass vaccination response. First, the virus is not among the most
contagious from person to person (compared to measles, for example),
requiring exposure to respiratory droplets that usually occurs only
among household or health care contacts.^98^ Second, successful
vaccination within four days of exposure to the virus can halt
infection.^99^ Over the past three years the federal government has
overseen the purchase and testing of large quantities of smallpox
vaccine, so that, as of this writing, there is sufficient vaccine to
inoculate every U.S. resident.^100^ The challenge for public health
planners is to devise feasible strategies to accomplish that task in a
reasonable time frame.

**B. Design Considerations**

A smallpox mass vaccination campaign most likely would be carried out at
designated smallpox clinics. Any smallpox clinic design must accommodate
two unique features of smallpox vaccination. First, vaccination involves
creating a localized infection with a live virus (vaccinia, or cowpox)
so special instructions must be given for post-inoculation wound care to
prevent inadvertent spread of the virus in the recipient (e.g.,
auto-inoculation of the eye) or in others.^101^ Second, since the Food
and Drug Administration (FDA) has only approved DryVax® for general
public use, all recipients of other vaccines must give witnessed
informed consent under an Investigational New Drug (IND) protocol prior
to the inoculation.^102^ Additional design considerations include:

-   **Pre- and post-event dual-use capability.** Clinic plans should
    address the needs of campaigns that occur in the absence of any
    known smallpox outbreak ("pre-event") or in the setting of a known
    or suspected release of the virus ("post-event").

-   **Clinic contact precautions.** Plans should address the need for
    rapid presumptive identification and respiratory isolation of
    suspected cases or contacts in a post-event setting.

-   **Crisis Counseling.** Plans should be able to accommodate mental
    health crisis counseling stations in both pre- and post-event
    scenarios.

-   **Testing.** Plans may need to accommodate stations for pregnancy
    testing and/or rapid HIV testing or stations at which information
    for off-site testing may be provided. Although there are no absolute
    contraindications to vaccination for a suspected case or contact in
    a post-event scenario, individuals may still decline the vaccine
    based on personal evaluation of risks and benefits. These
    individuals may then be recommended for isolation, as noted below.

-   **Isolation considerations.** Plans need to address isolation
    counseling in a post-event setting for those suspected cases or
    contacts who decline vaccination. This station would be linked to
    transport to designated isolation facilities.

**C. Model Patient Flow Plan**

These design considerations led researchers at the Department of Public
Health at Weill Medical College of Cornell University to develop the
sample smallpox clinic patient flow plan shown below (Figure 4).
Stations, spoken text, and annotations in grey (located on the right in
the diagram) would be used in a post-event scenario only. All other
stations would be used in both pre- and post-event settings.

The general clinic layout exemplifies the notion of "express lines"
described in the previous section, in that the clinic divides into
uncomplicated (left-hand side) versus complex (right-hand side) service
lines. In the post-event (grey) version of the clinic, anyone thought to
be a potential case or contact would be immediately separated from the
general flow of patients for physically separate processing in a
designated "Post-Event Precaution Area."

The following sub-sections describe in detail how this model clinic
would function in both pre- and post-event settings.

**Figure 4: Example of a Vaccination Clinic Plan**

![](media/image12.wmf)

**1. Pre-Event Patient Flow**

In a pre-event mass vaccination campaign, only the stations in the
left-hand and center portion of this flow diagram would be used (i.e.,
only the un-shaded portions). All persons entering the vaccination
center would be met by a greeter/screener and asked if they felt acutely
ill (any positive response in this pre-event setting would indicate a
non-smallpox intercurrent illness like acute asthma, myocardial
infarction, acute panic, etc.). These symptomatic patients would be
taken immediately to the medical evaluation area where health care
professionals could assess the severity of symptoms and the likelihood
of a serious underlying medical condition requiring further medical
care.

No uniform respiratory precautions would be needed for these symptomatic
patients in a pre-event scenario. Acutely ill patients may be
transported to a medical care facility, while those with a negative
medical evaluation could either be sent back through the standard
processing line or be sent to a duplicate set of stations with smaller
staff in a separate area for those symptomatic patients. Although
duplication of stations in a pre-event setting may appear redundant,
keeping these ill patients out of the general flow of asymptomatic
individuals may result in greater overall efficiency of the DVC
operation (i.e., avoiding bottlenecks due to increased triage and
management processing times for ill individuals).

Next, all potential vaccinees would be given forms and the means to fill
them out (i.e., a writing instrument and either a clipboard or a
tabletop on which to write). These individuals then would be directed to
briefing areas where either videotaped or live briefings would take
place with the opportunity for questions. Patients may be stationary
(i.e., seated) for these briefings or may have the opportunity to view
them while moving in line. After the briefing, persons with no
self-identified contraindications to vaccination would be given the
opportunity to sign the witnessed informed consent declarations for
receipt of the vaccine.

Individuals would then exit the briefing area to the triage area, where
persons with no contraindications would have their written information
verified by staff and those with potential contraindications further
questioned. From the triage station, rapid testing for pregnancy and/or
HIV may be offered to those interested or those uncertain about their
status. In this pre-event setting, some people may be denied vaccination
due to contraindications or may decline vaccination due to personal
weighing of its risk/benefit ratio. Others will proceed to vaccination
stations where those who have not yet signed their consent form may do
so and have it witnessed.

Prior to exiting the vaccination center, individuals would proceed to
the form collection and exit counseling station where DVC staff could
reiterate key points of vaccination site care and would check
completeness of forms for data entry. At any point in proceeding from
entry to exit, patients would have the opportunity to go to the mental
health/crisis counseling station located on-site. Those persons who opt
for counseling may re-enter the vaccination patient flow where they
left.

**2. Post-Event Patient Flow**

In a post-event setting, all symptomatic individuals and those who may
have come in contact with a smallpox case would be physically separated
from the main patient flow at the earliest possible station. On the
accompanying patient flow diagram, the grey-shaded comments and stations
would be used during post-event operation. The most important difference
is that these new stations will be physically distinct from the main
(non-case, non-contact) patient flow. The purpose of separating the
processing areas of these non-case, non-contact patients from presumed
cases and contacts is to minimize the potential exposure of healthy
vaccine recipients to individuals with possible smallpox exposure or
infection.

###  {#section-1 .unnumbered}

### As in pre-event clinic operation, entry screeners would ask all individuals walking through the door whether they feel ill. In the post-event setting, these screeners would also ask whether individuals have been exposed to someone who has smallpox. Anyone feeling ill or reporting direct contact with a smallpox patient would be sent to the Post-Event Precaution Area and would be instructed to put on an N95 ventilator (mask) to reduce the possibility of droplet transmission of the smallpox virus (an N95 ventilator provides 95% filter efficiency of particles with a diameter of less than 0.03 micrometers and where oil particles are not present).^98^ These individuals would then undergo screening at the medical evaluation station, where detailed questioning about symptoms and exposures and, if needed, an abbreviated physical examination could be performed. As shown in the diagram, these patients would be classified into one of four categories:  {#as-in-pre-event-clinic-operation-entry-screeners-would-ask-all-individuals-walking-through-the-door-whether-they-feel-ill.-in-the-post-event-setting-these-screeners-would-also-ask-whether-individuals-have-been-exposed-to-someone-who-has-smallpox.-anyone-feeling-ill-or-reporting-direct-contact-with-a-smallpox-patient-would-be-sent-to-the-post-event-precaution-area-and-would-be-instructed-to-put-on-an-n95-ventilator-mask-to-reduce-the-possibility-of-droplet-transmission-of-the-smallpox-virus-an-n95-ventilator-provides-95-filter-efficiency-of-particles-with-a-diameter-of-less-than-0.03-micrometers-and-where-oil-particles-are-not-present.98-these-individuals-would-then-undergo-screening-at-the-medical-evaluation-station-where-detailed-questioning-about-symptoms-and-exposures-and-if-needed-an-abbreviated-physical-examination-could-be-performed.-as-shown-in-the-diagram-these-patients-would-be-classified-into-one-of-four-categories .unnumbered}

###  {#section-2 .unnumbered}

### An acute non-smallpox illness such as myocardial infarction that would require immediate transport to a health care facility (labeled "CRITICAL" in the diagram)

### A subacute illness that is not suggestive of smallpox and does not require immediate transport to a health care facility, or no significant illness 

### An illness syndrome that is suggestive of smallpox (e.g., fever and/or severe backache and/or rash)

### A likely exposure to a case of smallpox but no evidence of symptomatic disease

Once sent to the presumed contact area, individuals in all four
categories remain wearing a mask as they undergo briefing, vaccination,
exit counseling, and/or transportation. This will minimize droplet
transmission from truly infectious individuals (through containment
under the mask) to uninfected individuals with either suspected or
documented contact (whose masks will prevent inhalation of possibly
infectious droplets). Upon exit from the clinic, only those individuals
with suspected smallpox or contact would be encouraged to maintain use
of the mask until they reach a treatment or domiciliary facility as
recommended by CDC.^102^ These facilities may range from designated
health care centers to the individual's home. Since there are no
absolute contraindications to vaccination for presumed cases or contacts
in a post-event setting, predetermined protocols will be required to
manage individuals in these categories who decline vaccination. Since
under evolving federal and state protocols these unvaccinated patients
may be required to undergo isolation for a specified period of time, the
clinic design includes a station for counseling and administrative
processing of these individuals.

**D. Sample Floor Plan**

Figure 5 shows how the aforementioned model smallpox clinic could fit
into the area of a typical high school basketball court (84ft. x 50ft.),
a possible site for DVC activities in the event of a large-scale
prophylaxis campaign. Note that the presumed contact area, including a
separate smaller briefing station, is physically distinct from the
non-contact areas. This floor plan shows only one large briefing area in
the non-contact area located on the court, although more could be set up
in adjacent rooms. Vaccine preparation, data entry, and clinic supplies
also may require use of adjoining rooms or staging areas.

**Figure 5: Sample Smallpox Vaccination Center Floor Plan**

![](media/image13.wmf)

###   {#section-3 .unnumbered}

### Section Four: Clinic Management/Command Structure  {#section-four-clinic-managementcommand-structure .unnumbered}

**8. Overview of Mass Prophylaxis Command Structure**

Incident management systems enable emergency responders to manage the
coordinated response to mass casualty incidents and other emergency
scenarios.^74^ A bioterrorism event or infectious disease outbreak may
be a large-scale event (e.g., similar in size and scope to an earthquake
or flood) requiring the activation of a community all-hazard response
plan. However, the response to a large-scale bioterrorism event poses
special challenges in that it may require use of local, state, and
federal medical stockpiles; coordination of multiple state and federal
agencies with non-overlapping fields of expertise (e.g., law enforcement
and public health); and outreach to a large proportion (if not all) of
the community for prophylaxis and treatment. As such, bioterrorism and
epidemic outbreak response epitomizes the type of complex
multi-jurisdictional operation for which the recently published National
Incident Management System (NIMS) has been designed.^74^ The local
implementation of a NIMS-based Command and Control function, described
here, would need to integrate with regional, state, and federal response
plans.

Mass prophylaxis involves a number of multiply--coordinated activities
(e.g., the Receipt, Store and Stage (RSS) centers for Strategic National
Stockpile supplies, where federal assets are transferred to state
control), but dispensing operations using DVCs pose perhaps the greatest
logistical challenge. As noted in Section One, DVC operations are the
critical point of contact between public health /emergency preparedness
activities and the wider public. The complexity and importance of DVC
operations necessitate that DVCs have a clearly defined command
structure that integrates seamlessly into the broader mass prophylaxis
campaign command structure which, in turn, integrates into the existing
local, regional, or state emergency management system. This nested
command structure is illustrated in Figure 6:

**Figure 6: DVC Command Integration**

**9. DVC Command Structure**

The National Incident Management System exemplifies a national movement
toward developing an all-hazards approach to natural disasters and
terrorist events at the local level using the principals of incident
command (IC).^76^ IC should also serve as the framework for management
of each DVC, because it provides a standardized structure that can be
easily integrated into larger campaign and all-hazards plans.
Furthermore, the inherent flexibility of IC allows for easy expansion or
contraction over time as the mass prophylaxis response demands.

Conceptually, the command system should be utilized in the planning,
mobilization, operation, and demobilization of each DVC. As demanded by
the characteristics of the response (e.g., population density), multiple
DVCs can be organized in an expanded IC structure, easily integrated
into the mass prophylaxis campaign management system and a community's
Emergency Operations Plan (EOP), and ultimately placed under a
multi-agency and multi-jurisdictional Unified Command (UC). Figure 6 has
shown the relation of the DVC IC structure to other mass prophylaxis
elements and the overall UC system. Figure 7 details the internal
command structure of a sample DVC. The various components, explained in
detail below, may be added or removed as required by the complexity and
size of the DVC.

# **A. Core Functions** {#a.-core-functions .unnumbered}

**1. Staff Positions**

The Incident Command System (ICS) serves as the framework for all of the
managerial support staff positions in the DVC. Standardized titles
should be used whenever possible to minimize misunderstandings in
terminology among different responding agencies. The core managerial
units and staff are as follows:

a.  ***DVC Command and Control***

The DVC Command and Control unit of the ICS functions as the highest
direct managerial unit of all individual DVC procedures. Decisions
regarding DVC procedures and control of information flow, both intra-
and inter-DVC, are centralized in the DVC Command and Control unit. The
DVC Command and Control unit is located in the DVC Incident Command Post
(DVC ICP), which should be contained within the DVC yet free from direct
patient traffic to ensure easy and immediate accessibility to various
ICS managers. The DVC Command and Control unit comprises a single Site
Commander (DVC SC) and a DVC Command Staff. In campaigns requiring more
than one DVC, each DVC SC will report to a single Dispensing Operations
Commander (DOC) who, in addition to overseeing all of the DVCs, will
serve as the liaison to the community's Emergency Operations Center
(EOC), the "nerve center" of the larger central Command and Control
function.

**Figure 7: Model DVC Command Structure**

![](media/image14.wmf)

> *1) DVC Site Commander (SC) and Dispensing Operations Commander (DOC)*
>
> The SC is responsible for overall management of DVC operations and for
> the formation of the DVC Site Action Plan (SAP---see A.2, below) with
> collaboration from the Planning and Operations Sections (see A.1.b.1
> and A.1.b.2, below). Optimally, the SC will be a public health or
> emergency management official. The SC has executive responsibility for
> directing all aspects of deployment, operation, and maintenance of the
> DVC.
>
> Campaigns using multiple DVCs will require an SC for each DVC, who
> will report to a single DOC located within the community's Emergency
> Operations Center (EOC). This DOC should be a senior public health
> official who can coordinate the operating activities of all DVCs in
> the campaign. The DOC is responsible as well for communication between
> the EOC and the DVCs to ensure that DVC management and operations
> integrate into the mass prophylaxis campaign system and the larger
> central Command and Control function.
>
> *2) DVC Command Staff*:
>
> a\) The DVC [Public Information Officer (PIO)]{.underline} serves as
> the local liaison between the EOC Joint Information Center (JIC) and
> the local community. The PIO, under directives from the SC, DOC, and
> ultimately the EOC, coordinates the release of information to the
> general public prior to the initiation of the mass prophylaxis program
> (e.g., DVC location; description of process), the release of updated
> directives as necessary, and progress reports. While each community's
> central Command and Control function will have its own senior
> information officers, the presence of DVC-level PIOs (if permitted by
> staffing constraints) may help foster a community-DVC link that
> ensures that the public receives accurate, focused, and timely
> information to support operational goals such as efficient patient
> flow.
>
> b\) The DVC [Liaison Officer]{.underline} serves as the DVC contact
> point for all involved responding agencies, including police, public
> health, emergency management, hospital, Federal, and other activated
> DVCs. The Liaison Office coordinates information and directives with
> representatives from all participating agencies to ensure focused and
> cooperative action.
>
> c\) The DVC [Medical Director]{.underline} and Chiefs of the
> Operations and Logistics sections (see b.2 and b.3, below), assists
> the SC and DOC in determining the timing of restocking of supplies
> from the distribution center. Additionally, the DVC Medical Director
> coordinates use of clinical protocols (e.g., written decision trees)
> to guide triage, prophylaxis, and treatment of patients. Finally, the
> Medical Director serves as quality control manager regarding all
> clinical activities in the DVC.
>
> d\) The DVC [Safety Officer]{.underline} is responsible for security
> at the DVC and directs activity of the security staff inside the DVC.
> In addition, this officer manages the health and safety of all DVC
> staff and ensures that operating conditions meet all Federal, state,
> and county health and safety regulations.

## ***b. DVC General Staff*** {#b.-dvc-general-staff .unnumbered}

The DVC General Staff is the organizational level comprising the major
functional sections of the DVC and includes the following:

> *1) DVC Planning Section*

The DVC Planning Section collects, evaluates, and disseminates real-time
information regarding DVC operations. The Planning Section also monitors
and reports resource use and allocation and prepares Situation Reports
(SitReps) to be incorporated in the development of the next SAP (see 2,
below).

2)  *DVC Operations Section*

> The Operations Section directs and coordinates DVC operational
> activities and ensures proper implementation of the SAP. Section
> subgroups under DVC Operations may include a Medical Section (covering
> triage and medical evaluation), a Pharmacy Section (covering
> dispensing of prophylactic medicines and vaccines and treatment
> regimens used for seriously ill patients), a Mental Health Section,
> and a Transportation Section, as well as the DVC Security Unit.

3)  *DVC Logistics Section*

> The Logistics Section responds to information generated from the
> Planning Section and coordinates the provision of required services
> and materials. Additionally, the Logistics Section will directly
> support the needs of the DVC staff (e.g., food, medical treatment).
>
> *4) DVC Finance/Administration Section*
>
> The Finance/Administration Section is responsible for DVC costs and
> financial considerations. The Finance/Administration Section records
> staffing hours, procurement costs, and unused and returnable SNS
> inventories. Furthermore, the Finance/Administration Section monitors
> the patient flow entering and exiting the DVC, including the
> collection of patient information/forms upon DVC exit. Finally, the
> DVC Finance/Administration Section may oversee the Translators Unit
> that will vary in size as determined by the needs of the community.

**2. Development of the DVC Site Action Plan (SAP)**

The DVC Site Action Plan (SAP) serves as a detailed operational guide to
the deployment and operation of individual DVCs and should be an
extension of the larger campaign goals of the Incident Action Plan (IAP)
established by the campaign's central Command and Control function. The
DVC SAP should address the following:

-   Policies, priorities, and objectives determined by the DVC Command
    and Control, integrated into the larger Unified Command function,

-   Organizational plans to meet these objectives developed by the DVC
    Planning and Operations Units

-   Support and service plans to accomplish the organizational plans
    developed by the DVC Logistics Unit (with input from the Security
    Officer).

-   Financial and resource considerations compiled by the
    Financial/Administration Unit.

The DVC SAP should explicitly state the prophylaxis goals of the
operational period (e.g., number of patients to prophylax over the next
24 hours) and detail all tactical actions (e.g., staffing levels at
individual stations) and supporting information. This SAP should be
updated prior to the initiation of the next operational period and
reflect the developments of previous periods. It is important to note
that SAP must be developed uniquely by each DVC to meet its specific
needs as time unfolds; however, it should integrate into the larger
campaign IAP (developed in the EOC of the community's central Command
and Control function) and thus should be in accordance with the larger
campaign goals.

**3. Job Action Sheets and Protocols**

Each staffing position in the ICS should have a prioritized Job Action
Sheet describing in detail the roles and responsibilities associated
with that particular position. Job Action Sheets serve to standardize
position duties and allow staff to move easily from one position to
another as the response dictates. Clinical protocols are required to
guide several of the core DVC functions (including triage, medical
evaluation, and drug triage and dispensing). These protocols, which must
be developed prior to any implementation of the DVC plan, are
incorporated into Job Action Sheets as a prioritized item number (e.g.,
Item #2: triage arriving patients according Triage Protocol sheet).
Optimally, each DVC will have an identical structure and thus Job Action
sheets should be uniformly developed by the DOC under the direction of
the community's EOC. However, due to such factors as size limitations or
unique target population characteristics, a particular DVC may require a
unique staffing structure and thus specialized Job Action Sheets.

**B. Additional Functions**

The ICS provides managerial structure for additional functions including
staff room and board, receipt, storage, and staging of resources, and
intra-DVC transportation for both staff and patients. Additionally, the
modular flexibility (i.e., functional units) of the ICS allows
incorporation of volunteer staff. For example, the DVC
Reception/Greeting Unit can contain a Volunteer Team to handle
appropriate duties. The DVC SAP should provide detailed procedures for
utilizing volunteers in DVC operations.

**C. Flexibility And Redundancy**

The ICS provides a time- and experience-tested management structure that
has been adopted by many state and local emergency response agencies.
ICS combines clear delineation of roles and reporting channels with
flexibility and adaptability to local requirements and resources. A mass
prophylaxis program framed in the ICS structure can rapidly respond to
changes in local DVC goals, resources, and personnel.

The size and scope of a mass prophylaxis campaign requires coordinated
collaboration among different agencies that previously may not have
undertaken joint large-scale community operations (e.g., public health
and law enforcement, U.S. Postal Service and emergency management) and
may have very different jurisdictional levels (e.g., county versus
Federal). The ICS structure (and related Incident Management System
(IMS)) allows for efficient interagency collaboration and communication.
The ICS operates with "unity of command," whereby information flows from
each organizational member to only one designated manager, creating an
internal quality control system.

ICS also allows for the coordination of multiple DVCs with clear lines
of communication. Each DVC has a single individual responsible for a
defined functional area that is consistent across all DVCs. A mass
prophylaxis program utilizing multiple DVCs linked to an overall Command
and Control function framed in ICS permits the efficient gathering of
community-wide data and the shifting of staff and resources between DVCs
(e.g., from a demobilizing DVC to those DVCs receiving an accelerating
patient flow rate).

In order to maintain appropriate staffing levels in a crisis situation,
emergency management planning often calls for "3-deep" staffing whereby
every position has two back-up personnel. However, given the potential
size of staff required for a mass prophylaxis campaign, this ratio may
be infeasible. An alternative would be to ensure each staff member's
familiarity with the roles and responsibilities of two additional and
related positions, creating in effect a reverse one to three ratio. For
example, a medical evaluator could familiarize oneself with the triage
and pharmacy protocols in case there was need for additional staff at
these positions. A protocol-driven ICS structure allows for easy review
of different staff duties. Additionally, an ICS structure creates an
inherent layer of redundancy, as managers are familiar with the
operational protocols guiding the members of the group.

The chief drawback of ICS is the need to adopt a new technical
vocabulary and response structure for those unfamiliar with its roles
and concepts. Consequently, time for education and training in ICS
should be factored into DVC plans. This up-front training time may
require significant buy-in in terms of staff time and resources from all
of the agencies involved in planning for mass prophylaxis campaigns.
However, simple Job Action Sheets, a clear, uniform command structure,
and defined protocols allow for rapid training that, when necessary, can
be done during the activation and/or escalation of a response.

**D. Command And Control Integration**

Operation of a DVC during an actual bioterrorism event would be a
complex endeavor requiring dynamic management to ensure efficient
operation and success of the overall prophylaxis campaign. Depending on
the magnitude of the terrorist event, the size and location of the
affected community, and the existing emergency response infrastructure,
the Command and Control function may be too far removed from actual
dispensing activities to effectively manage the minute-by-minute
operational requirements of a functioning DVC. Employing a DVC-specific
modified ICS structure as described in this section should improve the
effectiveness of DVC operations and contribute to the success of the
overall prophylaxis campaign *provided that* this DVC ICS functions as
an extension of the community's central Command and Control function.

**References**

1\. Jernigan J, Stephens D, Ashford D, et al. Bioterrorism-related
inhalational anthrax: the first 10 cases reported in the United States.
*Emerg Infect Dis.* 2001 Nov-Dec;7(6):933-44.

2\. WHO. Situation Updates - Severe Acute Respiratory Syndrome (SARS).
Available at: http://www.who.int/csr/sarsarchive/en/. Accessed March 31,
2003.

3\. Webby RJ, Webster RG. Are we ready for pandemic influenza?
*Science.* Nov 28 2003;302(5650):1519-1522.

4\. *A Governor\'s Guide to Emergency Management: Volume 2 - Homeland
Security*. Washington, D.C.: National Governor\'s Association; 2002.

5\. *Receiving, Distributing, and Dispensing the National Pharmaceutical
Stockpile: A Guide for Planners. Version 9.* Atlanta, GA: Centers for
Disease Control and Prevention (CDC); April 2002.

6\. Darling RG, Catlett CL, Huebner KD, Jarrett DG. Threats in
bioterrorism. I: CDC category A agents. *Emerg Med Clin North Am.*
2002;20(2):273-309.

7\. Meyer DV, Smith LE, Ahlquist A, Bray DA, Miller JM. Laboratory
Response Network - Web-based Help Desk, Proficiency Testing, and
Reporting. *Proc AMIA Symp.* 2003:933.

8\. Mothershead JL, Tonat K, Koenig KL. Bioterrorism preparedness. III:
State and federal programs and response. *Emerg Med Clin North Am.* May
2002;20(2):477-500.

9\. O\'Toole T, Inglesby TV. Epidemic response scenario: decision making
in a time of plague. *Public Health Rep.* 2001;116(Suppl 2):92-103.

10\. Perkins BA, Popovic T, Yeskey K. Public health in the time of
bioterrorism. *Emerg Infect Dis.* Oct 2002;8(10):1015-1018.

11\. Morse A. Bioterrorism preparedness for local health departments. *J
Community Health Nurs.* Winter 2002;19(4):203-211.

12\. Yetman RJ, Parks D, Taft E. Management of patients exposed to
biologic weapons. *J Pediatr Health Care.* 2002;16(5):256-261.

13\. Godley J. Bioterror emergency readiness: a local responsibility.
*Manag Care.* Nov 2003;12(11 Suppl):13-15.

14\. Thomson D. Mass immunization in the control of infectious disease.
*British Medical Journal.* 1966;5511:427-433.

15\. WHO. *Public Health Response to Biological and Chemical Weapons.*
Geneva: World Health Organization, 2001.

16\. Syndromic surveillance for bioterrorism following the attacks on
the World Trade Center\--New York City, 2001. *MMWR Morb Mortal Wkly
Rep.* 2002;51 Spec No:13-15.

17\. Buehler JW, Berkelman RL, Hartley DM, Peters CJ. Syndromic
surveillance and bioterrorism-related epidemics. *Emerg Infect Dis.* Oct
2003;9(10):1197-1204.

18\. Irvin CB, Nouhan PP, Rice K. Syndromic analysis of computerized
emergency department patients\' chief complaints: an opportunity for
bioterrorism and influenza surveillance. *Ann Emerg Med.* Apr
2003;41(4):447-452.

19\. Mostashari F, Fine A, Das D, Adams J, Layton M. Use of ambulance
dispatch data as an early warning system for communitywide influenzalike
illness, New York City. *J Urban Health.* Jun 2003;80(2 Suppl 1):i43-49.

20\. Bravata DM, Owens DK, Buckeridge DL, et al. *Bioterrorism
Preparedness and Response: Use of Information Technologies and Decision
Support Systems*: AHRQ Publication No. 02-E028. Rockville, MD: Agency
for Healthcare Research and Quality.; June 2002.

21\. Danzig R. *Catastrophic bioterrrorism: what is to be done?*
Washington, DC: Center for Technology and National Security Policy,
National Defense University; August, 2003 2003.

22\. Sox G, Maxymiv K. *Exercising the Strategic National Stockpile:
Lessons Learned and Tools for Application.* Washington, DC: Association
of State and Territorial Health Officials (ASTHO); 2004.

23\. Bentley JD. Hospital preparedness for bioterrorism. *Public Health
Rep.* 2001;116(Suppl 2):36-39.

24\. Wetter DC, Daniell WE, Treser CD. Hospital preparedness for victims
of chemical or biological terrorism. *Am J Public Health.*
2001;91(5):710-716.

25\. Henning KJ, Brennan PJ, Hoegg C, O\'Rourke E, Dyer BD, Grace TL.
Health system preparedness for bioterrorism: bringing the tabletop to
the hospital. *Infect Control Hosp Epidemiol.* Feb 2004;25(2):146-155.

26\. Taylor CW. Surge capacity: preparing your healthcare system. *Emerg
Med Serv.* Aug 2003;32(8):91-92.

27\. Shapiro DS. Surge capacity for response to bioterrorism in hospital
clinical microbiology laboratories. *J Clin Microbiol.* Dec
2003;41(12):5372-5376.

28\. Hupert N, Mushlin AI, Callahan MA. Modeling the public health
response to bioterrorism: using discrete event simulation to design
antibiotic distribution centers. *Med Decis Making.* Sep-Oct 2002;22(5
Suppl):S17-25.

29\. Hupert N, Bearman GM, Mushlin AI, Callahan MA. Accuracy of
screening for inhalational anthrax after a bioterrorist attack. *Ann
Intern Med.* Sep 2 2003;139(5 Pt 1):337-345.

30\. Follow-up of deaths among U.S. Postal Service workers potentially
exposed to Bacillus anthracis\--District of Columbia, 2001-2002. *MMWR
Morb Mortal Wkly Rep.* Oct 3 2003;52(39):937-938.

31\. Navas E. Problems associated with potential massive use of
antimicrobial agents as prophylaxis or therapy of a bioterrorist attack.
*Clin Microbiol Infect.* Aug 2002;8(8):534-539.

32\. Shepard CW, Soriano-Gabarro M, Zell ER, et al. Antimicrobial
postexposure prophylaxis for anthrax: adverse events and adherence.
*Emerg Infect Dis.* Oct 2002;8(10):1124-1132.

33\. Tierney BC, Martin SW, Franzke LH, et al. Serious adverse events
among participants in the Centers for Disease Control and Prevention\'s
Anthrax Vaccine and Antimicrobial Availability Program for persons at
risk for bioterrorism-related inhalational anthrax. *Clin Infect Dis.*
Oct 1 2003;37(7):905-911.

34\. Inglesby TV, O\'Toole T, Henderson DA. Preventing the use of
biological weapons: improving response should prevention fail. *Clin
Infect Dis.* 2000;30(6):926-929.

35\. Barbera JA, Macintyre AG. The reality of the modern bioterrorism
response. *Lancet.* 2002;360(Suppl):s33-34.

36\. Franz DR, Zajtchuk R. Biological terrorism: understanding the
threat, preparation, and medical response. *Disease-A-Month.*
2002;48(8):493-564.

37\. Bell DM, Kozarsky PE, Stephens DS. Clinical issues in the
prophylaxis, diagnosis, and treatment of anthrax. *Emerg Infect Dis.*
2002;8(2):222-225.

38\. Layton M. Bioterrorism preparedness checklist - local public health
agency perspective. Paper presented at: WHO Meeting on Informal
Discussions on Strengthening National Preparedness and Response to
Biological Weapons, Rome 2002. URL:
<http://www.who.int/emc/pdfs/WHOmeetingMarciLayton1.pdf>. Accessed April
2, 2004

39\. Binder P, Attre O, Boutin JP, et al. Medical management of
biological warfare and bioterrorism: place of the immunoprevention and
the immunotherapy. *Comp Immunol Microbiol Infect Dis.* Oct
2003;26(5-6):401-421.

40\. Blank S, Moskin LC, Zucker JR. An ounce of prevention is a ton of
work: mass antibiotic prophylaxis for anthrax, New York City, 2001.
*Emerg Infect Dis.* Jun 2003;9(6):615-622.

41\. Esbitt D. The Strategic National Stockpile: roles and
responsibilities of health care professionals for receiving the
stockpile assets. *Disaster Manag Response.* Jul-Sep 2003;1(3):68-70.

42\. Martin G. Anthrax: lessons learned from the U.S. Capitol
experience. *Mil Med.* Sep 2003;168(9 Suppl):9-14.

43\. Partridge R, Alexander J, Lawrence T, Suner S. Medical
counterbioterrorism: the response to provide anthrax prophylaxis to New
York City US Postal Service employees. *Ann Emerg Med.* Apr
2003;41(4):441-446.

44\. Inglesby TV, Grossman R, O\'Toole T. A plague on your city:
observations from TOPOFF. *Clin Infect Dis.* 2001;32(3):436-445.

45\. U.S. Postal Service may deliver medicine in the event of a
catastrophic incident. *U.S. Postal Service* \[February 18 2004 Press
Release\]. Available at:
http://www.usps.com/communications/news/press/2004/pr04_015.pdf.
Accessed April 2, 2004.

46\. Butler JC, Cohen ML, Friedman CR, Scripp RM, Watz CG. Collaboration
between public health and law enforcement: new paradigms and
partnerships for bioterrorism planning and response. *Emerg Infect Dis.*
2002;8(10):1152-1156.

47\. Reich DS. Modernizing local responses to public health emergencies:
bioterrorism, epidemics, and the model state emergency health powers
act. *J Contemp Health Law Policy.* Spring 2003;19(2):379-414.

48\. GAO. *Public Health Response to Anthrax Incidents of 2001.*
Washington, DC: United States General Accounting Office; October 2003.
GAO-04-152.

49\. GAO. *Most Urban Hospitals Have Emergency Plans but Lack Certain
Capacities for Bioterrorism Response.* Washington, DC: United States
General Accounting Office; August, 2003. GAO-03-924.

50\. Flowers LK, Mothershead JL, Blackwell TH. Bioterrorism
preparedness. II: The community and emergency medical services systems.
*Emerg Med Clin North Am.* 2002;20(2):457-476.

51\. Knouss RF. National disaster medical system. *Public Health Rep.*
2001;116(Suppl 2):49-52.

52\. Landesman LY. *Public health management of disasters: a practice
guide*. Washington, D.C.: American Public Health Association; 2001.

53\. Blendon RJ, DesRoches CM, Benson JM, Herrmann MJ, Taylor-Clark K,
Weldon KJ. The public and the smallpox threat. *N Engl J Med.*
2003;348(5):426-432.

54\. Greenberg MI, Jurgens SM, Gracely EJ. Emergency department
preparedness for the evaluation and treatment of victims of biological
or chemical terrorist attack. *J Emerg Med.* 2002;22(3):273-278.

55\. Schultz CH, Mothershead JL, Field M. Bioterrorism preparedness. I:
The emergency department and hospital. *Emerg Med Clin North Am.* May
2002;20(2):437-455.

56\. Montello MJ, Ostroff C, Frank EC, Haffer AS, Rogers JR. 2001
anthrax crisis in Washington, D.C.: pharmacists\' role in screening
patients and selecting prophylaxis. *Am J Health Syst Pharm.*
2002;59(12):1193-1199.

57\. Malecki J, Brumback CL. Need for physicians trained in preventive
medicine and public health: implications for a bioterrorism response. *J
Public Health Manag Pract.* Mar-Apr 2003;9(2):89-90.

58\. Rippen HE, Gursky E, Stoto MA. Importance of bioterrorism
preparedness for family physicians. *Am Fam Physician.* May 1
2003;67(9):1877-1878.

59\. Bartlett JG. Mobilizing professional communities. *Public Health
Rep.* 2001;116(Suppl 2):40-44.

60\. Barbera J, Macintyre A, Gostin L, et al. Large-scale quarantine
following biological terrorism in the United States: scientific
examination, logistic and legal limits, and possible consequences.
*JAMA.* 2001;286(21):2711-2717.

61\. Glass TA. Understanding public response to disasters. *Public
Health Rep.* 2001;116(Suppl 2):69-73.

62\. Bloem K. Treating the sick: capacity of the US Health Care System
to respond to an epidemic. *Public Health Rep.* 2001;116(Suppl 2):34-35.

63\. Greenberg MI, Hendrickson RG. Report of the CIMERC/Drexel
University Emergency Department Terrorism Preparedness Consensus Panel.
*Acad Emerg Med.* Jul 2003;10(7):783-788.

64\. Laughrun GM. Preparing your hospital to respond to a terrorist
attack. *Am J Health Syst Pharm.* 2002;59(14):1329-1330.

65\. Pollard WE. Public perceptions of information sources concerning
bioterrorism before and after anthrax attacks: an analysis of national
survey data. *J Health Commun.* 2003;8 Suppl 1:93-103; discussion
148-151.

66\. Kuhr S, Hauer JM. Intergovernmental preparedness and response to
potential catastrophic biological terrorism. *J Public Health Manag
Pract.* 2000;6(4):50-56.

67\. Bioterrorism: coordination and preparedness - Heinrich, J.
*Subcommittee on Government Efficiency, Financial Management, and
Intergovernmental Relations. Committee on Government Reform*.
Washington, D.C.: United States General Accounting Office; 2001.

68\. Stephenson J. Monkeypox outbreak a reminder of emerging infections
vulnerabilities. *JAMA.* Jul 2 2003;290(1):23-24.

69\. Terriff CM, Tee AM. Citywide pharmaceutical preparation for
bioterrorism. *Am J Health Syst Pharm.* Feb 1 2001;58(3):233-237.

70\. Auf der Heide E. *Disaster Response: Principles of Preparation and
Coordination*. St. Louis: Mosby; 1989. Chapter 8, Triage.

71\. Haffer AS, Rogers JR, Montello MJ, Frank EC, Ostroff C. 2001
anthrax crisis in Washington, D.C.: clinic for persons exposed to
contaminated mail. *Am J Health Syst Pharm.* 2002;59(12):1189-1192.

72\. Benedek DM, Holloway HC, Becker SM. Emergency mental health
management in bioterrorism events. *Emerg Med Clin North Am.* May
2002;20(2):393-407.

73\. Stein BD, Tanielian TL, Vaiana ME, Rhodes HJ, Burnam MA. The role
of schools in meeting community needs during bioterrorism. *Biosecur
Bioterror.* 2003;1(4):273-281.

74\. Ridge T. *National Incident Management System.* Washington, DC:
Department of Homeland Security; March 2004.

75\. Koplan J. CDC\'s strategic plan for bioterrorism preparedness and
response. *Public Health Reports.* 2001;116(Suppl 2):9-16.

76\. Auf der Heide E. *Disaster Response: Principles of Preparation and
Coordination*. St. Louis: Mosby; 1989. Chapter 9, The Incident Command
System (ICS).

77\. Brown BS, Prior SD. Public health and public trust: the defining
dyad for the 21st century. *Int J Emerg Ment Health.* Fall
2002;4(4):239-244.

78\. Hall MJ, Norwood AE, Ursano RJ, Fullerton CS. The psychological
impacts of bioterrorism. *Biosecur Bioterror.* 2003;1(2):139-144.

79\. Vanderford ML. Communication lessons learned in the Emergency
Operations Center during CDC\'s anthrax response: a commentary. *J
Health Commun.* 2003;8 Suppl 1:11-12.

80\. State of California Mass Prophylaxis Guide. *Emergency Medical
Services Authority of California*. Available at:
http://www.emsa.cahwnet.gov/dms2/draft_mass_prophy_final.pdf. Accessed
April 2, 2004.

81\. Simple triage and rapid treatment. *CERT-Los Angeles*. Available
at: http://www.cert-la.com/triage/start.htm. Accessed 09/09/02, 2002.

82\. Suspected exposure to bioterrorism agent emergency department
triage guidelines. *Stanford University Medical Center Bioterrorism and
Emergency Preparedness Task Force* \[web-page\]. 12/08/01. Available at:
http://www.stanfordhospital.com/pdf/bioterrorism/EDTriageGuideline.pdf.
Accessed November 15, 2002.

83\. Holloway HC, Norwood AE, Fullerton CS, Engel CC, Jr., Ursano RJ.
The threat of biological weapons. Prophylaxis and mitigation of
psychological and social consequences. *JAMA.* 1997;278(5):425-427.

84\. Hupert N, Cuomo J. Bioterrorism and Epidemic Outbreak Response
Model (BERM). *Agency for Healthcare Research and Quality (AHRQ)*.
Available at: http://www.ahrq.gov/research/biomodel.htm. Accessed April
2, 2004.

85\. Capital Health. *Mass immunization campaigns: A \"how to\" guide
based on experience during the February 2000 Capital Health
meningococcal immunization campaign*. Alberta, Canada; 2000.

86\. Osterholm MT. How to vaccinate 30,000 people in three days:
realities of outbreak management. *Public Health Rep.* 2001;116(Suppl
2):74-78.

87\. New model developed for outbreak readiness. *Healthcare Benchmarks
Qual Improv.* Sep 2003;10(9):101-102.

88\. Giovachino M, Carey N. Modeling the consequences of bioterrorism
response. *Mil Med.* 2001;166(11):925-930.

89\. *Emergency Management and Public Health: How Are Emergencies
Handled in the Commonwealth of Massachusetts?*: Massachusetts Department
of Health; 2001.

90\. *California Hospital Bioterrorism Response Planning Guide*.
Sacramento, California: Department of Health Services and Emergency
Medical Services Authority of California; 2002.

91\. *Guidelines for the development of local action plan for use of the
following assets: state pharmaceutical stockpiles (SPS) and National
Pharmaceutical Stockpile (NPS).* Florida: Florida Department of Health,
Office of Emergency Management; 2002.

92\. Kaplan EH, Craft DL, Wein LM. Emergency response to a smallpox
attack: the case for mass vaccination. *Proceedings of the National
Academy of Sciences of the United States of America.*
2002;99(16):10935-10940.

93\. Halloran ME, Longini IM Jr., Nizam A, Yang Y. Containing
bioterrorist smallpox. *Science.* 2002;298(5597):1428-1432.

94\. Bozzette SA, Boer R, Bhatnagar V, et al. A model for a
smallpox-vaccination policy. *N Engl J Med.* Jan 30 2003;348(5):416-425.

95\. Henderson DA, Inglesby TV, Bartlett JG, et al. Smallpox as a
biological weapon: medical and public health management.
*JAMA.*1999;281(22):2127-2137.

96\. Breman JG, Henderson DA. Diagnosis and management of smallpox. *N
Engl J Med.* 2002;346(17):1300-1308.

97\. Lane JM, Goldstein J. Evaluation of 21st-century risks of smallpox
vaccination and policy options. *Ann Intern Med.* Mar 18
2003;138(6):488-493.

98\. Mack T. A different view of smallpox and vaccination. *N Engl J
Med.* 2003;348(5):460-463.

99\. Breman JG, Arita I, Fenner F. Preventing the return of smallpox. *N
Engl J Med.* 2003;348(5):463-466.

100\. Fauci AS. Smallpox vaccination policy\--the need for dialogue. *N
Engl J Med.* 2002;346(17):1319-1320.

101\. Lane JM. Smallpox and smallpox vaccination. *N Engl J Med.*
2002;347(9):691; author reply 691-692.

102\. Smallpox Response Plan and Guidelines (Version 3.0). Centers for
Disease Control and Prevention. Exp. Date 06/2003. Available at:
http://www.bt.cdc.gov/agent/smallpox/response-plan/index.asp. Accessed
February 21, 2003.

**Glossary**

# **Bioterrorism:** The intentional release of disease-causing bacteria, viruses, toxins, and/or spores on civilian populations in order to induce fear and panic by causing illness and/or death. {#bioterrorism-the-intentional-release-of-disease-causing-bacteria-viruses-toxins-andor-spores-on-civilian-populations-in-order-to-induce-fear-and-panic-by-causing-illness-andor-death. .unnumbered}

**Biowarfare:** The use of disease-causing bacteria, viruses, toxins,
and/or spores upon military personnel to achieve strategic objectives
during warfare.

**Category A Biological Agents/Diseases:** Biological agents classified
as high-risk by the Centers for Disease Control and Prevention (CDC)
because of their relative ease in dissemination and transmission, their
high infectivity and virulence, impact on public order, and requirement
of unique and extraordinary public health preparedness and response.^6^
These agents are: anthrax, botulism, plague, smallpox, tularemia, and
viral hemorrhagic fevers.

**Dispensing:** The process of providing medical prophylaxis to targeted
populations in the community. The third step in the drug delivery chain
from stockpile to distribution to dispensing.

**Dispensing/Vaccination Center (DVC):** A single location where
antibiotic or vaccine dispensing activities occur. Also know as a Point
of Dispensing, or POD.

**Distribution:** The process of delivering bulk medical materials (e.g.
SNS supplies) from stockpile and staging areas to the dispensing
centers. Second step in drug delivery chain from stockpile to
distribution to dispensing.

**Incident Command System:** An organizational structure for emergency
response based on clear and consistent definitions of roles,
responsibilities, and reporting channels of all participating personnel.

**Logistics:** Refers to resource procurement and management to achieve
objective goals; the section of ICS responsible for providing
facilities, services, and materials for the incident (not personnel).

**Mass Prophylaxis:** The process by which an entire community is to
receive prophylactic drugs/vaccines over a defined period of time in
response to possible exposure to a biological agent.

**National Pharmaceutical Stockpile (NPS):** See Strategic National
Stockpile (SNS)

**Strategic National Stockpile (SNS):** The Federal cache of
pharmaceuticals, vaccines, medical supplies, equipment, and other items
to augment local supplies of critical medical care targeted to
high-priority diseases and conditions (based on the CDC Category A
agents). Also refers to the program and support staff managing and
operating this cache. Formerly known as the National Pharmaceutical
Stockpile (NPS).

**Operations:** Refers to implementation of planned processes using
resources provided by Logistics; the section of ICS responsible for all
tactical processes at the incident.

**Protocol:** A detailed script, decision tree, or patient flow diagram
intended to guide decisions and action at specific DVC stations (e.g.,
triage).

**Push Package:** The unit cache of medical supplies created by the SNS
that will be shipped to an incident within 12 hours of Federal
authorization.

**Surveillance:** The process of monitoring community-wide illness
syndromes or disease occurrence to detect a possible bioterrorist attack
or natural outbreaks of unusual diseases.

**Triage:** The systematic and protocol-driven evaluation of
patient-based information to determine type of treatment or assistance
needed. DVC triage may direct patients to further medical evaluation,
mental health evaluation, pharmacist-assisted drug dispensing, or none
of the above.

**Vendor Managed Inventory (VMI):** Large caches of specific
pharmaceutical agents stored by manufacturers under preexisting
contractual arrangement with CDC SNS and available for mass shipment to
affected areas as needed for continuing prophylaxis and response
activities after use of one or more Push Packages.

**[A]{.smallcaps}cronyms[:]{.smallcaps}**

**DOC =** Dispensing Operations Commander

**DVC IO** **=** Dispensing/Vaccination Center Information Officer

**DVC SC =** Dispensing/Vaccination Center Site Commander

**DVC =** Dispensing/Vaccination Center (also known as POD)

**EOC =** Emergency Operations Center

**HAN =** Health Alert Network

**IAP** **=** Incident Action Plan

**IC =** Incident Commander of campaign

**ICS =** Incident Command System

**IMS =** Incident Management System

**JAS =** Job Action Sheet(s)

**SAP =** Site Action Plan for DVC

**SitRep =** Situation Reports

**SNS =** Strategic National Stockpile and Strategic National Stockpile
Program

(formerly NPS)

**Appendixes**

**Appendix A. Advisory Board**

Agency for Healthcare Research and Quality,

U.S. Department of Health and Human Services..... Sally Phillips, R.N.,
Ph.D.

Arnold and Marie Schwartz College of Pharmacy

Long Island University................................... Robert V.
DiGregorio, Pharm.D.

Centers for Disease Control and Prevention.................. Richard
Nolan

David Adcock

Joe Henderson

National Association of County and

City Health Officials..................................... Zarnaaz Rauf,
M.P.H.

Larry Raine, Dr.P.H.

New York City Department of Health

and Mental Hygiene.......................................Susan Blank,
M.D., M.P.H.

> Isaac Weisfuse, M.D., M.P.H.

New York City Office of Emergency Management........... Samuel Benson,
AEMT-P

Edward Gabriel, AEMT-P, M.P.A.

Office of the Assistant Secretary for Public Health

> Emergency Preparedness, Department of Health
>
> and Human Services.......................................CDR Matthew
> Tarosky, Pharm.D.

Orange County FL Health Services Division,

Office of Disaster and Emergency Services......\...\...\...\....David L.
Freeman, REMT-P

**Appendix B. Thematic Bibliography**

# **I. DVC Examples and Draft Plans** {#i.-dvc-examples-and-draft-plans .unnumbered}

1.  Haffer AS, Rogers JR, Montello MJ, Frank EC, Ostroff C. 2001 anthrax
    crisis in Washington D.C.: clinic for persons exposed to
    contaminated mail. *Am J Health-Syst Pharm.* 2002;59:1189-1192.

2.  Montello MJ, Ostroff C, Frank EC, Haffer AS, Rogers JR. 2001 anthrax
    crisis in Washington, D.C.: pharmacists' role in screening patients
    and selecting prophylaxis. *Am J Health-Syst Pharm.*
    2002;59:1193-1199.

3.  "Three-day bioterrorism drill begins in an Oklahoma town."
    Associated Press. *The New York Times*. 2002; April 13:A11.

4.  "Official react to bioterrorism drill." Brown, JL. *The Washington
    Post*. 2002; April 12. URL:
    [http://www.washingtonpost.com/wp-dyn/articles/A36763-2002Apr12.html.
    Accessed
    9/10/02](http://www.washingtonpost.com/wp-dyn/articles/A36763-2002Apr12.html. Accessed 9/10/02).

5.  Inglesby TV. Observations from the Top Off exercise. *Public Health
    Reports*. 2001 Supplement 2;116:64-75.

6.  Osterholm MT. How to vaccinate 30,000 people in three days:
    realities of outbreak management. *Public Health Reports*. 2001
    Supplement 2;116:74-78.

7.  "Guidelines for the development of a local action plan for use of
    the following assets: state pharmaceutical stockpile (SPS) and
    Strategic National Stockpile(SNS)." Florida Department of Health,
    Office of Emergency Operations. April 2002.

8.  "National pharmaceutical stockpile: guidelines for counties."
    Central Florida Regional Domestic Security Task Force. Draft
    Version 3. August 16, 2002.

9.  *State of California Mass Prophylaxis Planning Guide.* Emergency
    Medical Services Authority of California. 2003. Available at:
    http://www.emsa.cahwnet.gov/dms2/draft_mass_prophy_final.pdf.
    Accessed April 2, 2004

10. Smallpox Response Plan and Guidelines (Version 3.0). Centers for
    Disease Control and Prevention. Web Site:
    http://www.bt.cdc.gov/agent/smallpox/response-plan/index.asp.
    Accessed on February 21, 2003.

**II. Web-Based Resources**

11. "Anthrax clinical pathways for clinics (updated 01/09/02)." SUMC
    Bioterrorism and Emergency Preparedness Task Force, Stanford
    University Medical Center. URL:
    [http://www.stanfordhospital.com/pdf/bioterrorism/anthraxclinicalpathwaysclinics.pdf.
    Accessed
    9/10/02](http://www.stanfordhospital.com/pdf/bioterrorism/anthraxclinicalpathwaysclinics.pdf. Accessed 9/10/02).

12. "Suspected exposure to bioterrorism agent emergency department
    triage guidelines (updated 12/08/01)." SUMC Bioterrorism and
    Emergency Preparedness Task Force, Stanford University Medical
    Center. URL:
    [http://www.stanfordhospital.com/pdf/bioterrorism/EDTriageGuideline.pdf
    Accessed
    9/10/02](http://www.stanfordhospital.com/pdf/bioterrorism/EDTriageGuideline.pdf Accessed 9/10/02).

13. "Bioterrorism preparedness checklist -- local public health agency
    perspective." Layton, M. Informal Discussions on Strengthening
    National Preparedness and Response to Biological Weapons; World
    Health Organization. March 6-8,2002. URL:
    [http://www.who.int/emc/pdfs/Marcy%20Layton.pdf](http://www.who.int/emc/pdfs/Marcy Layton.pdf).
    Accessed 9/10/02.

**III. National Association of County and City Health Officials
(NACCHO)**

14. "Infrastructure, organizational, policy, and resource implications
    for implementing CDC guidelines for managing and using a deployed
    national pharmaceutical stockpile." NACCHO planning document 8/02

15. "Prototype position description for the top manager for coordination
    and support of a statewide SNS preparedness program." NACCHO
    planning document 8/02.

16. Clearinghouse records of city, county, and state emergency
    preparedness plans. NACCHO. URL: <http://bt.naccho.org/print.asp>.
    Accessed 9/10/02.

**IV. Public Health Disaster Management**

17. Landesman LY. *Public health management of disasters: a practice
    guide*. Washington, D.C.: American Public Health Association; 2001

18. Auf der Heide, Erik. *Disaster Response: Principles of Preparation
    and Coordination.* Center for Excellence in Disaster Management &
    Humanitarian Assistance: Honolulu, 2001. Chapter 8: Triage. URL:
    <http://216.202.128.19/dr/DisasterResponse.nsf/section/08?opendocument>.
    Accessed 9/10/02

19. "CERT-Los Angeles: simple triage and rapid treatment." URL:
    <http://www.cert-la.com/triage/start.htm>. Accessed 9/10/02

20. "Health disaster management: guidelines for evaluation and research
    in the Utstein style: executive summary." Task Force on Quality
    Control of Disaster Management. URL:
    [http://pdm.medicine.wise.edu/executiv2.htm Accessed
    9/10/02](http://pdm.medicine.wise.edu/executiv2.htm Accessed 9/10/02).

21. Hamburg MA. Challenges confronting public health agencies. *Public
    Health Reports*. 2001 Supplement 2;116:59-63.

22. Glass TA. Understanding public response to disasters. *Public Health
    Reports*. 2001 Supplement 2;116:69-73.

23. O'Toole T, Inglesby TV. Epidemic response scenario: decision making
    in a time of plague. *Public Health Reports*. 2001 Supplement
    2;116:92-103.

24. O'Toole, T. The problem of biological weapons: next steps for the
    nation. *Public Health Reports*. 2001 Supplement 2;116:108-111.

25. Fee E, Brown TM. Preemptive biopreparedness: can we learn anything
    from history? *American J of Pub Health*. 2001 May; 91(5):721-726.

26. Rubin J. Institutional networks: regional response to disasters.
    *Public Health Reports*. 2001 Supplement 2;116:45-48.

27. Kuhr S, Hauer JM. Intergovernmental preparedness and response to
    potential catastrophic biological terrorism. *J of Pub Health
    Management and Practice.* 2000 July;64(4):50-56.

28. Bartlett JG. Mobilizing professional communities. *Public Health
    Reports*. 2001 Supplement 2;116:40-44.

29. The Treatment of Mass Civilian Casualities in a National Emergency.
    McCarroll JR, Skudder PA, Eds. *Medical Education for National
    Defense*, Washington, D.C. 1967.

30. *Summary Report on National Emergency Medical Care*. The American
    Medical Association, Chicago, IL. 1959.

31. *Community Outreach* *-- Mass Prophylaxis*: *A Mass Casualty Care
    Strategy for Biological Terrorism Incidents.* US Army Soldier and
    Biological Chemical Command, Homeland Defense Office, Department of
    Defense; June 1, 2002.

32. Inglesby TV. Preparedness for terrorist attack. Federal Document
    Clearing House Congressional Testimony. Capitol Hill Hearing
    Testimony. Senate Governmental Affairs. April 18, 2002 Thursday.

33. Ridge T. *National Incident Management System.* Washington, DC:
    Department of Homeland Security; March 2004.

## **V. Hospital Preparedness and Capacity** {#v.-hospital-preparedness-and-capacity .unnumbered}

34. Bentley JD. Hospital preparedness for bioterrorism*. Public Health
    Reports*. 2001 Supplement 2;116:36-39.

35. Bloem K. Treating the sick: capacity of the US health care system to
    respond to an epidemic. *Public Health Reports*. 2001 Supplement
    2;116:34-35.

36. Wetter DC, Daniell WE, Treser CD. Hospital preparedness for victims
    of chemical or biological terrorism. *American J of Pub Health*.
    2001 May; 91(5):710-716.

37. Giovachino M, Carey N. Modeling the consequences of bioterrorism
    response. *Mil Med*. 2001;166(11):925-930.

38. Johnson LA. Hospitals, state health system readying staff, equipment
    for terrorism. Associated Press. BC Cycle; June 6, 2002.

39. *17 Critical Benchmarks for Bioterrorism Preparedness Planning*.
    FDCH Federal Department and Agency Documents. Regulatory
    Intelligence Data. Department of Health and Human Services. June 6,
    2002.

40. *California Hospital Bioterrorism Response Planning Guide*.
    California Department of Health Services and Emergency Medical
    Services Authority of California. June, 2002. URL:
    <http://www.emsa.cahwnet.gov/dms2/ca_hosp_guide.pdf>. Accessed
    9/10/02

## **VI. Federal Response** {#vi.-federal-response .unnumbered}

41. "Technical assistance for anthrax response," Interim-Final Draft for
    Review June 2002. National Response Team. 2002, August 2.

42. Kennedy EM. National leadership in confronting bioterrorism: 2.
    *Public Health Reports*. 2001 Supplement 2;116:116-118.

43. Knouss RF. National disaster medical system. *Public Health
    Reports*. 2001 Supplement 2;116:49-52.

**VII. Agency for Healthcare Research and Quality (AHRQ) and Centers for
Disease Control and Prevention (CDC)**

44. Bravata D, McDonald K, Owens D, et al. Bioterrorism Preparedness and
    Response: Use of Information Technologies and Decision Support
    Systems (Evidence Report/Technology Assessment No. 59 (Prepared by
    University of California San Francisco-Stanford Evidence-based
    Practice Center under Contract No. 290-97-0013). AHRQ Publication
    No. 02-E028. Rockville, MD: Agency for Healthcare Research and
    Quality. June 2002.

45. "Biological and chemical terrorism: strategic plan for preparedness
    and response." Centers for Disease Control and Prevention.
    *Morbidity and Mortality Weekly Report: Recommendations and
    Reports*. 2000, April 21; 49(RR-4):1-14.

46. "Prevention and control of influenza: recommendations of the
    advisory committee on immunization practices." Centers for Disease
    Control and Prevention. *Morbidity and Mortality Weekly Report*.
    2002, April 12;51(RR-3):1-31.

47. "Update: investigation of bioterrorism-related anthrax and interim
    guidelines for exposure management and antimicrobial therapy,
    October 2001." Centers for Disease Control and Preparedness.
    *Morbidity and Mortality Weekly Report*. 2001 October 26;
    50(42):909-919.

48. Phillips S, Burstin H, Dillard CD, Clancy CM. AHRQ\'s bioterrorism
    research portfolio: real linkages in real time. *Health Serv Res.*
    Feb 2004;39(1):xi-xv.

**VIII. World Health Organization Guidelines**

49. "Public health response to biological and chemical weapons." *WHO
    Guidelines*. World Health Organization; November 2001.

**IX. National Pharmaceutical Guidelines**

50. *Receiving, Distributing, and Dispensing the National Pharmaceutical
    Stockpile: A Guide for Planners. Version 9 -- Draft.* Centers for
    Disease Control and Prevention; April 2002.

## **X. Smallpox** {#x.-smallpox .unnumbered}

51. Smallpox Response Plan and Guidelines (Version 3.0). Centers for
    Disease Control and Prevention. Web Site:
    http://www.bt.cdc.gov/agent/smallpox/response-plan/index.asp.
    Accessed on February 21, 2003.

52. Henderson DA, Inglesby TV, Bartlett JG, Ascher MS, Eitzen E,
    Jahrling PB, et al. Smallpox as a biological weapon: medical and
    public health management. Working Group on Civilian Biodefense. JAMA
    1999;281(22):2127-37.

53. Mack T. A different view of smallpox and vaccination. N Engl J Med
    2003;348(5):460-3.

54. Fauci AS. Smallpox vaccination policy\--the need for dialogue. N
    Engl J Med 2002;346(17):1319-20.

55. Breman JG, Henderson DA. Diagnosis and management of smallpox. N
    Engl J Med 2002;346(17):1300-8.

56. Kaplan EH, Craft DL, Wein LM. Emergency response to a smallpox
    attack: the case for mass vaccination. Proc Nat Acad Sci United
    States of America. 2002;99(16):10935-40.

57. Halloran ME, Longini IM, Jr., Nizam A, Yang Y. Containing
    bioterrorist smallpox. Science 2002;298(5597):1428-32.

58. Bozzette SA, Boer R, Bhatnagar V, Brower JL, Keeler EB, Morton SC,
    et al. A model for a smallpox-vaccination policy. N Engl J Med
    2003;348(5):416-25

## **XI. Psychological Effects of (Bio-)Terrorism and Management** {#xi.-psychological-effects-of-bio-terrorism-and-management .unnumbered}

59. Galea S, Ahern J, Resnick H, et al. Psychological sequelae of the
    September 11 terrorist attacks in New York City. *N Eng J Med*.
    2002;346(13):982-7.

60. Hoge CW, Pavlin JA. To the editor: psychological sequelae of
    September 11. *N Eng J Med*. 2002;347(6):443-444.

61. Yehuda R. Post-traumatic stress disorder. *N Eng J Med*.
    2002;346(2):108-130.

62. Holloway HC, Norwood AE, Fullerton CS, Engel CC, Ursano RJ. The
    threat of biological weapons: prophylaxis and mitigation of
    psychological and social consequences. *JAMA* 1997;278(5):425-427.

63. Glass TA, Schoch-Spana M. Bioterrorism and the people: how to
    vaccinate against panic. *Clin Infect Dis*. 2002 Jan
    15;34(2):217-223.

**Appendix C. Technical Appendix: Modeling DVC Operations**

**Note:** In the following discussion, the term "DVC patient flow rate"
refers to the planning concept of an average rate of patient processing
over the duration of the mass prophylaxis response, not as an actual
measure of the unpredictable rate at which patients may show up at DVCs
in the aftermath of a bioterrorist attack. The equations and spreadsheet
models presented here use this average patient flow rate for two
reasons. First, there is no good data to guide prediction of patient
surge arrivals at DVCs, so any model that tried to estimate surge
arrivals would be inherently prone to error. Second, it is likely that,
with appropriate use of law enforcement and public information
campaigns, planners could maintain constant patient flow rates at their
DVCs by controlling entry.

The goal of mass prophylaxis planning is to ensure that dispensing of
necessary antibiotics, vaccines, or other medical supplies to target
populations occurs within a designated time frame. In certain cases, the
time frame for response will be fixed (e.g., in a widespread smallpox
attack wherein vaccination of all potential contacts should take place
within 4 days of exposure). However, most other factors in the response
scenario will either be variable (e.g., population affected) or under
planners' control (e.g., number of DVC sites, number of staff, and
station process times).

**A. Modeling Approach**

The spreadsheet programs included with this Planning Guide allow
planners to model DVC activities based on two assumptions. First, all
actions in the DVC are considered *deterministic,* rather than
stochastic, processes. While this eliminates naturalistic variability
from elements like patient interarrival time and station processing
times, it greatly enhances the simplicity and understandability of model
estimates. Second, these spreadsheet programs give results for DVCs at
what is called "steady-state operation." The definition of steady-state
in this setting is that queues occurring at any station in any given DVC
in the system do not experience a net increase in length over the course
of the prophylaxis campaign. Another way of saying this is that the rate
of arrivals equals the rate of departures from the DVC as a whole and
from every station in the DVC, as shown in the figure:

The first step in modeling DVC activities is to determine this average
patient flow.

**1. Determining Campaign, DVC, and Station Flow**

Under the deterministic steady-state assumption, individuals arrive at
each DVC station at a constant rate throughout operation of the
prophylaxis campaign. The flow at these stations can be calculated from
features of the campaign as a whole (i.e., overall processing rate
across a community), the number of DVCs, and the DVC patient flow plan.
For ease in calculations and to avoid errors, these flows should all be
in the same unit of time (e.g., per minute).

***a. Average Campaign Flow***

Average campaign flow represents the total number of individuals
processed per unit of time across the entire affected community. It is a
function of the total population in the target community (e.g., town
population) and the length of the prophylaxis campaign. Algebraically,

> i\) R~Campaign~ = Pop ÷ T

Where: R~Campaign~ = Average campaign flow (or rate)

> Pop = Total size of population (or number of patients)
>
> T = Length of Time for campaign

This calculation will give a campaign flow rate of patients per unit
time of campaign. T can be days, hours, or minutes. To set T at minutes,
first determine how many hours per day the campaign will be operating
(e.g., the DVCs will be open 24 hours per day). The equation for T in
terms of minutes becomes:

> ii\) T = D × H × M

Where: D = Length of campaign in days

> H = Hours of operation per day
>
> M = Minutes of operation per hour

Combining i) and ii) gives a calculation of campaign flow in terms of
Patients per Minute, as follows:

> iii\) R~Campaign~ = Pop ÷ (D × H × M)

For example, a campaign targeting 10,000 people over 5 days, operating
at 8 hours per day will have an average flow of 10,000÷(5×8×60) = 4.17
pts/min.

Assuming R~Campaign~ is fixed and constant, it becomes the variable to
which all staffing calculations ultimately become tethered.
Consequently, changes in either staff per DVC, number of DVCs, or
station process times, for example, will necessarily cause changes in
each other such that the campaign flow remains constant.

***b. Average DVC Flow***

The average DVC flow (denoted as R~DVC~) is a measure of the total
patients per unit of time each DVC in a campaign can process. Three
methods of determining the average DVC flow include a) User-defined; b)
Briefing-defined; c) DVC number-defined.

*1) User-defined DVC Flow*

The average number of patients per unit of time processed can be based
on past experiences or live exercises (denoted as R~DVC-UD~). However,
as explained in more detail below in Section 3: Staffing Calculations,
the number of staff per station and per DVC is directly proportional to
this flow. Consequently, a higher flow (i.e., larger number of patients
processed per unit time) demands a larger number of working staff.
Spatial constraints (i.e., number of staff a given DVC can accommodate)
may not allow for this number and thus the DVC flow may need to be
decreased.

*2) Briefing-defined*

On-site briefings to ensure patient education and consent may be
required by Federal, state, or local regulations (e.g., as currently
required for all Investigational New Drug (IND) protocols). Because of
both their duration (i.e., briefings likely will have the longest
process time of all DVC stations) and their scope (i.e., all patients
will have to be briefed), briefings will determine the patient flow for
each DVC. Regardless of their placement within a DVC flow plan, the
briefing will impact other stations both upstream and downstream.
Upstream stations should be capable of achieving the briefing flow in
order to fill the briefing space to capacity (and thus prevent wasted
space and materials). At the same time, upstream stations should not
operate faster than the briefing flow as this will produce queues of
increasing length outside of the briefing area. Downstream stations
should also be capable of achieving the briefing flow to prevent queues
of increasing length.

Consequently, planners creating DVCs with on-site briefings should
determine their DVC flow by equating it to the briefing flow (denoted as
R~DVC-BD~). The briefing flow is a function of two characteristics: the
number of patients simultaneously briefed (the product of number of
briefing rooms and room capacity) and the length of the briefing.
Algebraically,

> iv\) R~DVC~ = R~DVC-BD~ = (N~Rooms~ × N~Patients\ per\ room~ ) ÷
> T~Briefing~

Where: N~Rooms~ = Number of briefing rooms

> N~Patients\ per\ room~ = Capacity of each room
>
> T~Briefing~ = Length of each briefing (in minutes for R~DVC-BD~ to be
> equal to patients per minute)

*3) DVC Number-defined DVC Flow*

In certain cases, planners may decide on a maximum number of DVCs in
their campaign prior to calculating patient flow. The average DVC flow
can be calculated as follows:

> v\) R~DVC~ = R~DVC-ND~ = R~Campaign~ ÷ N~DVC~

Where: R~DVC-ND~ = Average DVC patient flow using the number-defined
method

> N~DVC~ = Maximum number of DVCs within the campaign.

Combining equation iii) with v) will allow calculation of DVC flow in
patients per minute as follows:

> vi\) R~DVC~ = R~DVC-ND~ = Pop ÷ (D × H × M × N~DVC~)

***c. Average Station-Specific Flow***

The station-specific flow is a function of 2 variables: the average DVC
flow and the proportion of that flow that arrives at the station of
interest. This proportion is determined by features of DVC patient flow
plan. The DVC flow plan determines the paths that patients may travel.
The proportion of patients who take a given path is determined by
calculating the percentage taking that path at each branch point along
the way (percentages which must be assigned by planners). These
station-specific probabilities are then multiplied by the overall
patient flow for the DVC (R~DVC~) as calculated above. Algebraically,
for any station *i*, within a DVC pathway containing a total of I
sequentially numbered stations, the corresponding station-specific flow
(R~S*i*~) can be calculated as follows:

vii\) R~S*i*~ = R~DVC~ × ∏ (P*~i~*)

Where: *i* = Sequential number of station located within flow path of
DVC

> I = Total number of stations within flow path containing this station
>
> P*~i~* = Proportion of patients entering into station *i*

The following example demonstrates this method. This diagram represents
a simple DVC layout. Circles represent individual stations within the
DVC and the station of interest is highlighted.

To calculate the station-specific average flow of Station 4, first
identify the pathway a patient would follow from entrance into the DVC
to reach the station (represented by the thick lines) and multiply the
corresponding estimated probabilities. Finally, multiply this result by
the average DVC flow. By example:

Assume: R~DVC~ = 10 pts/min

> *p1* = 1.0
>
> *p2* = .80
>
> *p3* = .8
>
> *p4* =.5

Then: R~S4~ = (*p4* × *p3* × *p2* × *p1*) × R~DVC~ or

> = (.5 × .8 × .8 × 1.0) × 10 pts/min
>
> = 3.2 pts/min

Certain stations may have multiple pathways of entrance. In such case,
the product of the chain of probabilities of each associated pathway
should be added and this total then multiplied by R~DVC~.

**2. Determining the Number of DVCs**

The total number of DVCs must be sufficient to process the total
population within the given time frame or the campaign will not be a
success. Consequently, the most direct method of calculating the total
number of DVCs is to divide the average campaign flow by the average DVC
flow, as follows:

viii\) N~DVC~ = R~CAMPAIGN~ ÷ R~DVC~

The total number of DVCs within a campaign is inversely proportional to
the average flow of each DVC. Decreasing the average DVC flow will
increase the number of necessary DVCs. Decreasing the number of DVCs
(e.g., because of resource limitations) will increase the necessary
average DVC flow to process a population within the given time frame of
the campaign. Fixing the number of DVCs or the DVC flow rate (e.g., by
mandating that all DVCs must operate at 100 patients per minute) will
force a change in the overall campaign flow and therefore in the overall
time needed to complete the prophylaxis campaign.

**3. Staffing Calculations**

The number of staff required for a prophylaxis campaign can be
calculated for each station within a DVC, for the DVC as a whole, and
for the campaign in total. The number of staff is a function of patient
flow, average process time, and the ratio of staff to patient. Under the
deterministic representation of a steady-state (where queues, if
existent, are constant in length), staff can be calculated using the
following general formula:

ix\) S = R × T × I

Where: S = Staff

> R = Entering patient flow
>
> T = Process time
>
> I = Ratio of staff to patients

Calculating staff then becomes a matter of plugging in the appropriate R
as explained in Section 1, ensuring the unit of time measure for T and R
are consistent, and determining the ratio of staff to patients for the
activity.

***a. Station-specific staffing***

Two factors determine the optimal number of staff at a DVC station:
patient flow (the average number of patients arriving at a station per
unit time) and the station-specific processing time (the time needed to
process the average patient at that station). When a DVC is running at
steady-state operation, staff activities and patient arrivals are
balanced so that no *new* bottlenecks or queues form. (Note: a system
that is functioning at steady-state can have queues, but they do not get
any longer during the steady-state operation.) A simple formula shows
how these two factors determine the optimal number of staff for each
station under steady-state operation:

> x\) S~Station~ = R~Station~ × T~Station~ × I~Station~
>
> Where S~Station~ = Staff at station
>
> R~Station~ = Patient flow arriving at station (patients per minute)
>
> T~Station~ = Processing time for station
>
> I~Station~ = Staff-to-Patient ratio at station (e.g., I=1 if one staff
> member is required for the entire duration of processing of each
> patient)

***b. Total DVC staffing***

The total number of staff needed to run a DVC is the sum of the number
of staff needed at each station:

> xi\) S~DVC~ = ∑ S~Station.~

**B. Definitions of DVC Efficiency**

Two measures reflect the efficiency of DVC design: bottlenecks and staff
utilization. If more patients arrive than can be processed by DVC staff,
a bottleneck will occur at one or more of the stations inside the DVC. A
bottleneck at a single station can decrease efficiency of the entire DVC
by reducing processing rates at other stations in one of two ways: long
lines at one station may interfere with operations at other stations
(e.g., by blocking access), and staff may be shifted to the affected
station, thereby compromising efficiency of other areas. To solve
bottlenecks, DVC managers may need to increase the total number of DVC
staff or decrease processing times (e.g., by shortening forms or
protocols).

If the DVC plan overestimates either the need for staff at a given
station or the need for entire DVCs to achieve community-wide
prophylaxis, waste in the form of staff underutilization or excess
"down-time" will occur. As noted, in a large-scale mass prophylaxis
operation staff will be one of the resources in shortest supply. In that
case, inefficient use of staff at one station or DVC can be expected to
decrease the efficiency of some other aspect of the prophylaxis
campaign. In plain language, if staff at a DVC or station find
themselves idle during a large-scale event, the DVC plan that assigned
them to that station needs reevaluation.