States not prepared to distribute emergency meds in strategic stockpile
States not prepared to distribute emergency meds in strategic stockpile
Only 15 given 'green light' rating showing readiness
In a finding that raises the question of whether the chaotic response to Hurricane Katrina was a foreshadowing of things to come, a national assessment has determined that 35 states are not ready to distribute medical supplies from the Strategic National Stockpile (SNS) even if the feds deliver the life-saving materials in a matter of hours following an attack or disaster.
As a safeguard against natural disaster, emerging infections or terrorist attack, the federal SNS is a national repository of antibiotics, chemical antidotes, antitoxins, life-support medications, IV administration equipment, airway maintenance supplies, and medical/surgical items. The Centers for Disease Control and Prevention reports that the SNS can be deployed to any area of the country within 12 hours. According to the CDC, "critical to the success of this initiative is ensuring capacity is developed at federal, state, and local levels to receive, stage, and dispense SNS assets."
Unfortunately, in a surprising number of states the dispensing is where planning may break down, leading to inadequate distribution of the supplies even after they have been quickly shuttled into the area in need.
That's one of the key findings in a new report by Trust for America's Health (TFAH) entitled "Ready or Not? Protecting the Public's Health from Disease, Disasters, and Bioterrorism." Though some states and municipal health jurisdictions are clearly doing better than others, the one-word national answer to the report's title question appears to be, "not."
Still, the TFAH report found that only 15 states have achieved the "green status" rating given by the CDC to signal readiness to distribute the SNS. The system is based on the traffic light colors, with the states and jurisdictions stuck on amber or red. The CDC does not release the ratings, but they were gleaned from other sources by the TFAH, a Washington, DC-based non-profit, non-partisan organization dedicated to making disease prevention a national priority.
"[Green status] means that they have gone through an exercise where CDC has tested the ability of the jurisdiction to rapidly deploy [the SNS]," explains Jeff Levi, PhD, TFAH executive director. "Its CDC's job to get [the SNS] to the state. Once it arrives in the state the question is how quickly can they deploy it to points of distribution so that it actually gets to the people that need it? We found only 15 jurisdictions were able to pull that off. Fifteen out of 51 jurisdictions is not a good performance."
The group was not able to determine which of the states failing to achieve the green light were ranked as amber or outright red. "A number of jurisdictions said they were hopeful in the next six months or a year they would be able to get [green status], but so far they have not," he says. "[Lack of readiness] does not limit their access to the SNS. It [speaks to] the effectiveness of the SNS. It is only as effective as its ability to get stuff out to people as opposed to health departments."
Given the green light
The jurisdictions that have achieved the green-light ranking to rapidly distribute SNS supplies include Chicago, New York City and the following states: Alabama, Delaware, Florida, Illinois, Louisiana, Michigan, Mississippi, Missouri, New York, Oklahoma, Rhode Island, Tennessee, Texas, Virginia and Washington. Conspicuously absent despite their proximity to past targets are Washington, D.C., and New Jersey. "Taking New Jersey as an example, the fact that they do not have green status for the strategic national stockpile is clearly problematic in a jurisdiction that is close to the epicenter of the 9/11 attacks," Levi says. "One would have hoped they would have done better. To me the most disturbing of these [findings] are such low scores on the SNS."
In the wake of the report, New Jersey officials cited a lack of federal funding allocations for disaster preparedness, according to the Associated Press. Overall, the TFAH report concluded that five years after the September 11th and anthrax attacks, emergency health preparedness is still inadequate in America. "The nation is nowhere near as prepared as we should be for bioterrorism, bird flu, and other health disasters," Levi says. "We continue to make progress each year, but it is limited. As a whole, Americans face unnecessary and unacceptable levels of risk."
The report contains state-by-state health preparedness scores based on 10 key indicators to assess health emergency preparedness capabilities. (See scores) Among the factors analyzed were ability to distribute medicines and supplies from the SNS, maintain the laboratory capacity and personnel to detect biologic agents used in a terrorist attack, maintain year-round laboratory surveillance for influenza, and provide hospital bed-surge capacity for at least two weeks during a moderate pandemic. The report also reviewed seasonal flu vaccination rates and pneumonia vaccination rates for persons over 65, electronic disease data reporting, nursing workforce availability, and funding for public health services.
All 50 U.S. states and the District of Columbia were evaluated. Half of the states scored six or less on the scale of 10 indicators. Oklahoma scored the highest with 10 out of 10; California, Iowa, Maryland, and New Jersey scored the lowest with four out of 10. States with stronger surge capacity capabilities and immunization programs scored higher in the report, since four of the measures focus on these areas. However, the evaluation was not sensitive enough to tell, for example, whether Oklahoma's top ranking reflected the state's continuing response to the 1995 Oklahoma City bombing, the worst terrorist attack on U.S. soil prior to 9/11.
"We essentially look at the indicators and in a sense that becomes a surrogate for some assessment of a level of preparedness," Levi explains. "I think it is safe to say one of the reasons somewhat more rural states did better this time than others is that they tend to face less of an issue around surge capacity. If there is a bias in the indicators that we chose that would be it. One of the challenges that we face in doing this report is that there is relatively little publicly available data, so we have to work with what is available. And in this case, [Oklahoma] did well. Certainly, Oklahoma got the wakeup call [on terrorism] a lot earlier than other places. That may be a factor, but to what degree we are not in a position to judge."
While pleased with the high ranking, Mike Cruther, MD, Oklahoma health commissioner, says it is essentially a snapshot of a point in time and that the criteria selected by the TFAH changes from year to year. "The efforts by OSDH staff and its state and local partners to better prepare for terrorism response or any catastrophic health emergency are ongoing," he says. "[They] will not be judged by an interest group report but will stand on their own if and when disaster strikes our state."
Hospital beds full in two weeks
Other key findings in the report included that 25 states would run out of hospital beds within two weeks of a moderate pandemic flu outbreak. "We used CDC software that is available on-line that allows states to plug in appropriate numbers and determine – depending on the severity of the pandemic – how quickly they would run out of hospital beds," Levi says. "We looked at the first two weeks, but most waves of a pandemic last 10 to 12 weeks, so even in a moderate pandemic almost everyone would run out at a certain point."
In addition, 40 states currently face a shortage of nurses, suggesting that staffing would be woefully inadequate if hospitals were pressed into surge capacity issues. "That is a larger systematic issue obviously," he says. "You can have all the pop-up [temporary] hospitals you want but if you don't have pop-up health care workers you are not going to be able to meet demand. Things like surge capacity and nursing shortages reflect issues in the overall health care system in the jurisdiction. Those are not going to be easily resolved in the context of just focusing on preparedness."
Other findings in the report included:
- Rates for vaccinating seniors for the seasonal flu decreased in 13 states.
- Eleven states and D.C. lack sufficient capabilities to test for biological threats.
- Four states do not test year-round for the flu, which is necessary to monitor for a pandemic outbreak.
- Six states cut their public health budgets from fiscal year (FY) 2005 to 2006; the median rate for state public health spending is $31 per person per year.
Linking cash and accountability
The report also examines the need to strengthen funding and accountability for public health preparedness. Preparedness is a shared responsibility among the federal, state, and local governments, with the CDC and Health Resource Services Administration (HRSA) at the U.S. Department of Health and Human Services (HHS) in charge of overseeing the use of federal funds devoted to health emergency readiness. Since 2004, over $90 million have been cut from the CDC's preparedness funds that are allocated to states, and more than $23 million have been cut from HRSA funds allocated for state hospital preparedness. The cuts have occurred before many basic preparedness goals have been met, threatening to halt or reverse progress that has been achieved, the report warns.
"One issue here is that as federal money has come have states maintained their own effort and/or increased their own effort?" Levi says. "Because it is not strictly a federal responsibility, but there has been some unpredictability in the stability of federal funds. When there is unpredictability you are more likely to spend money on one-time events, purchases and the like, rather than building a core capacity because you are not sure whether you are going to be able to maintain that core capacity. Having core capacity to respond is probably the most important thing that states could be doing."
Moreover, the federal government currently does not consistently, objectively measure or provide state-by-state information to help Americans and policymakers assess how prepared their communities are to respond to health threats, the report found. Accordingly, the TFAH recommended that the federal government should establish improved "optimally achievable" standards that every state should be accountable to meet. The results should be made publicly available to lend transparency to bioterrorism and disaster planning, the report argues.
"The federal government has not established a minimum standard of preparedness that every state must meet," Levi says. "We think that where you live shouldn't determine how well protected you are. The federal government ought to be saying here are minimum things every state ought to be able to do."
The federal government has been assessed on key steps in the pandemic flu planning process, he adds, noting, "We should be able to do the same thing on a state level with how states are doing for bioterrorism preparedness and pandemic flu preparedness. There are ways that funding could be tied to performance standards, to maintenance of effort at that state and local level. But in exchange for that the federal government ought to be providing a guarantee of some stable level of support over time."
Other recommendations
• Establish temporary health benefits for the uninsured or underinsured during states of emergency. This benefit is necessary to ensure that sick people will stay home, and the uninsured and underinsured will seek treatment in times of emergency, helping to prevent the unnecessary spread of infectious diseases, including resulting from acts of bioterrorism or a pandemic flu outbreak.
• Designate a single senior official within the HHS to be in charge of and accountable for all public health programs. This senior official would streamline government efforts and be the clear leader during times of crisis.
• Improve emergency surge capacity capabilities by integrating all health resources and partnering with businesses and community groups in planning, and increasing stockpiles of needed equipment and medications.
• Expand the volunteer medical workforce and invest in the recruitment of the next generation of the public health workforce.
• Modernize technology and equipment and strengthen research and development.
• Include the public in emergency planning and modernize risk communication.
[Editor's note: TFAH's complete report and state-by-state materials are available at: www.healthyamericans.org]
In a finding that raises the question of whether the chaotic response to Hurricane Katrina was a foreshadowing of things to come, a national assessment has determined that 35 states are not ready to distribute medical supplies from the Strategic National Stockpile (SNS) even if the feds deliver the life-saving materials in a matter of hours following an attack or disaster.Subscribe Now for Access
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