# Presentation: 322615

## Evidence Report on Regionalization of Bioterrorism Preparedness and Response Planning

**Dena M. Bravata, M.D., M.S.**
- Project Director
- Stanford-University of California, San Francisco Evidence-based Practice Center

**Notes:**
Moderator: 
Dena Bravata is the project director for the current project of the Stanford-UCSF Evidence-based Practice Center. She and her colleagues are preparing an Evidence Report to synthesize the published evidence about ongoing efforts to regionalize services for bioterrorism preparedness and response planning. 

## Evidence Report

- Purpose: to synthesize the published evidence on a given topic
- Method:
- Search literature for relevant articles
- Abstract data from each article
- Evaluate the evidence

**Notes:**
1. Moderator: 
Dena, can you begin by telling us what an Evidence Report is?

Answer: 
Purpose of an evidence report is to synthesize the published evidence on a given topic
For a typical evidence report on a medical topic (such as whether a particular intervention or therapy is effective), you would search the medical literature for relevant studies, abstract data from each article, then evaluate the evidence to determine the effectiveness of the intervention
The complexities of this topic demands a somewhat different approach.

## Medical, public health
Identify key tasks for responding to bioterrorism-related events
Supply chain, logistics
Identify best practices for designing regional stockpiles and distribution systems 
Emergency management
Identify key components of mutual aid agreements
Government documents 
Identify ongoing bioterrorism response planning efforts

- Identify key tasks for responding to bioterrorism-related events
- Supply chain, logistics
- Identify best practices for designing regional stockpiles and distribution systems
- Emergency management
- Identify key components of mutual aid agreements
- Government documents
- Identify ongoing bioterrorism response planning efforts

- Literature Sources

**Notes:**
2. Moderator:
How are you going about it for this project?

Answer: 
We started by seeking relevant articles from 4 literature sources: 
Medical and public health literatures: Identified a large number of bioterrorism related events such as the 2001 anthrax cases, response to the SARS outbreak, responses to natural disasters such as hurricanes and earthquakes.  From this we identified the key tasks that would have to be performed during a bioterrorism response.
Supply chain/logistics literature: We have been trying to apply lessons learned from companies like FedEx, Hewlett-Packard, and grocery stores that have designed cost-effective supply chains for the manufacture and distribution of goods and services to retailers and eventually customers to the problem of regionalization of acquiring, storing, distributing, and dispensing antibiotics, vaccines, and other essential materiel for a bioterrorism response.
Emergency management literature: apply lessons learned from the way that emergency management professions have developed mutual aid agreements to be able to rapidly deploy resources such as equipment and personnel to augment surge capacity at disaster sites 
Government documents: to make sure we identify the relevant state and federal initiatives from the various organizations contributing to the ongoing bioterrorism preparedness and response planning from the efforts that Brad just talked about at HRSA, to those onging at FEMA, CDC, VA, among many others. 

## Design a completely new system
Consider bioterrorism preparedness planning in the context of existing response infrastructures
Public health
First responders
Hospital systems
Laboratories

- Consider bioterrorism preparedness planning in the context of existing response infrastructures
- Public health
- First responders
- Hospital systems
- Laboratories

- Two Approaches

**Notes:**
3. Moderator:
Why is it important to identify these ongoing efforts?
Policy makers interested in regionalization of services for bioterrorism preparedness can take one of two approaches:
They could try to design a completely new system for a regional response to bioterrorism or they 
Can consider bioterrorism preparedness planning in the context of existing response infrastructures. Because the relevant local responders such as public health officials, first responders, hospital administrators, laboratory personnel among others all work within existing regional systems, it seems essential to consider the design bioterrorism response planning in the context of the regional systems in which these responders function.

## Planning and Preparedness
Field assessment and triage 
Diagnosis 
Management of acutely ill 
Prevention 
Surveillance 
Outbreak Investigation
Communication 
Emergency Management

- Field assessment and triage
- Diagnosis
- Management of acutely ill
- Prevention
- Surveillance
- Outbreak Investigation
- Communication
- Emergency Management

- Key TasksSubtasksResources

**Notes:**
4. Moderator:
What are you finding?

Answer: 
From reports of these bioterrorism-related events and a number of bioterrorism preparedness plans we extracted information about the key tasks that were required to mount a response to a bioterrorism-related events. For each key task, we have identified a series of subtasks and the relevant resources such as personnel, supplies, and information required to perform that task. For each of these key tasks, we are considering the evidence that supports regionalization of goods and services needed to perform that task.

Next slide 

## Preliminary Findings

- Many systems
- Few evaluations

**Notes:**
Although we are still in the process of collecting data, thus far we have found many systems that are directly relevant to bioterrorism preparedness such as bioterrorism surveillance systems, the National Pharmaceutical Stockpile, the Laboratory Response Network, among others....we have found very few evaluations of these systems that specifically describe the most effective methods of regionalizing each of the key tasks.

## Utility of the Evidence Report

- Identify regional response organizations
- Identify available evidence about regionalization of key tasks
- Simulations of regionalization
- Stockpiling/distributing antibiotics/vaccine
- Surveillance

**Notes:**
5. Moderator: 
How will your results be useful?

Answer: 
We hope that when it is finished, our Evidence Report will be useful in at least 2 main ways.
1st: if you are a policy maker in a particular community or region—perhaps a public health official or an emergency management professional—you would be able to use our report to identify the other key response organizations in your region.

2nd: if you were interested in knowing the evidence about best practices for performing one of the key tasks—such as surveillance—you could use our report to identify the published evidence regarding regionalization of that service.

Also, for two areas where we have found very little evidence about regionalization, we are developing simulations of regionalization.  These are to address questions of regionalization for the stockpiling and distribution of antibiotics and vaccines for mass prophylaxis and treatment in the event of a noncontagious bioterrorism attack with an agent such as anthrax and for surveillance for a covert bioterrorism event.

## To obtain a copy of the Evidence Report

- “Regionalization of Bioterrorism Preparedness and Response” (available after December 2003)
- Free of charge:
- www.ahrq.gov/clinic/epcix.htm
- AHRQ Clearinghouse: 800.358.9295

**Notes:**
6. Moderator: 
When will your current evidence report be published and how can interested members of the audience order a copy?

Answer: 
The draft of the Evidence Report will be finished in December of this year. Both Evidence Reports can be ordered from the Agency for Healthcare Research and Quality (AHRQ) free of charge by visiting their website or calling the AHRQ Clearinghouse at  800.358.9295.

## Information Technology for Bioterrorism Preparedness

- Detection/Diagnosis (78 systems)
- Management and Prevention (18 systems)
- Surveillance systems (90 systems)*
- Reporting and Communication (26 systems)*
- Integrated Surveillance, Communication, and Command and Control (7 systems)*
- *High relevance to surge capacity and regionalization

**Notes:**
Supplemental Question #1

Moderator: 
I understand that your team recently completed an Evidence Report on available information technologies for bioterrorism preparedness and response. Can any of the technologies described in that report assist local or regional planners as they approach issues of surge capacity and regionalization? 

Answer: 
In our previous Evidence Report, we described 217 systems for use by clinicians and public health officials during a bioterrorism response.  The types of systems are outlined on the slide and included those for detection, diagnosis, management, and prevention.  

We found a variety of systems with relevance to issues of surge capacity and regionalization.  Primarily, the systems were designed for communication, command and control, and surveillance.  For example, there are command and control systems designed to display available hospital capacity, EMS units, and other first responders overlaid with data coming in from hospitals with syndromic surveillance data or other information about the unfolding outbreak.  

## Humanitarian Logistics

- Primary Objective: Timely mobilization of financing and goods
- Tasks: procurement, transport, tracking and tracing, customs clearance, local transportation, warehousing and last mile delivery
- Fritz Institute
- Non-profit
- Mission: apply logistics expertise from the corporate/academic community to humanitarian relief
- http://www.fritzinstitute.org

**Notes:**
Supplemental Question #2

Moderator: 
You mentioned earlier that you were reviewing the supply chain literature for articles and cases that might be relevant to regionalization of services for bioterrorism responses.  Can you tell us more about that?

One key example of an industry working to apply the lessons of supply chain management and logistics to bioterrorism preparedness would be the humanitarian relief organizations such as the International Federation of Red Cross and Red Crescent Societies, UNICEF, World Food Programme, among many others.  

The primary objective of these organizations is to coordinate the timely mobilization of billions of dollars and tons of goods from international donors to vulnerable beneficiaries at disaster sites across the world.  Specifically, they are responsible for the procurement, transport, tracking and tracing, customs clearance, local transportation, warehousing and last mile delivery of goods.  Supply chain management and logistics are concerned with the science of cost-efficient management of all the steps between manufacturing the supplies to their delivery at the door of their intended user.

We are collecting and analyzing data about best practices in humanitarian logistics and trying to apply these lessons to regionalization of the supply chain for the timely delivery of goods and personnel for a bioterrorism response.  For listeners who are particularly interested in this topic, I would direct them to the Fritz Institute: a non-profit organization whose mission is to apply the logistics expertise from the corporate and academic communities to humanitarian relief efforts.