Within Middlesex County, NJ there are approximately 295,000 residences with an estimated 2.7 persons per home. That equals 817,100 persons who need medication within 25 municipalities in 48 hours following a Bioterrorism event. The burden on local health agencies to provide medication within the set parameters becomes more difficult with decreasing resources. Recognizing that traditional PODS may not be able to reach the necessary at-risk population within the 48 hours, we have developed a Door-to-Door Medication Delivery System. The goals of the program are to ensure that medication gets to every household within the 48 hour window and to shift the burden from the County Health Dept. to the municipality. Our Door to Door model, based on regular Postal Model operations, uses the assumptions of delivery to the entire population of a geographic area using municipal first responders, municipal employees, and volunteers in some municipalities in the County.
Our public health department has partnered with one municipality (The Pilot program) on this initiative. Over the past three years, we have developed a distribution plan, conducted discussion meetings and tabletop exercises, culminating with a full functional exercise which took place in June, 2018.
Using their own municipal personnel and volunteers (police, fire, OEM, first aid), the city delivered pamphlets (in place of medication) describing the Door to Door program and its benefits, to every residence in their city. Beginning with a NIXLE* alert and reverse 911 to notify the residents, 50 responders showed up to methodically deliver medication” to the city, broken down by fire district. The functional exercise was conducted on a Saturday morning and all medication” for the entire municipality was delivered in four (4) hours, well within the 48 hour window.
County and Local health departments will have significant challenges when tasked to dispense emergency medical countermeasures to their mass populations. Staff shortages, funding shortages and logistics issues all create a situation that necessitates novel and creative solutions. Greatly leading to the success of the program is that municipalities already have a buy-in” because it's their own town. They are ensuring a plan for the health of their own residents in a crisis.
Following a large scale biological attack or disaster, the rapid response and the quick delivery of medical countermeasures to the population at risk is vital for saving lives. The traditional POD method of medication dispensing requires enormous staffing resources that may not be available at the time of the disaster. Middlesex County has over 800,000 residents distributed in 25 municipalities. Alternate delivery methods are necessary to reach our entire population in the 48 hours set by the CDC.
In 2009, President Obama issued an executive order citing, The U.S. Postal Service has the capacity for rapid residential delivery of medical countermeasures for self administration across all communities in the United States. The Federal Government shall pursue a national U.S. Postal Service medical countermeasures dispensing model to respond to a large-scale biological attack.” . Unfortunately the Federal Government did not follow through with Postal Service countermeasures.
The post office delivers mail to every residence almost every day so it seems logical to develop a plan to model their delivery system in certain jurisdictions. Fourteen(14) of our 25 municipalities have populations under 25,000. They are the current target size for this model program, although land size and density have some influence in choosing the municipalities for the program. We modified the postal plan to a door-to-door plan which strictly uses municipal workers and volunteers of the designated municipality. In this partnership, the responsibility for the program is taken on by the Municipal Office of Emergency Management instead of Local Health. The local health department remains a support agency.
Our local use of the Door-to-Door program is an innovative way to enhance the tradition POD method of delivery by enlisting local responders and volunteers to take on roles usually done by local health departments. It effectively lifts the burden off the local health department for dispensing medication to that municipality. The benefits to that municipality is the good will the local government generates to its residents. It also reduces the amount of people at the traditional POD and eliminates having people congregate in crowds.
The goal of the Door to Door Distribution program is to alleviate some of the burden off the massive traditional POD system but also to design a program that was reasonable for a municipality to adopt. In order to accomplish this, we partnered with the municipality very early in the development process. The municipality we chose had to have less than 25,000 residents, an urban setting, and a willingness to partner. Once we, the LHD, had a template plan outlined, we had the municipality review it to add their input and structure a plan that fit their needs. We brought other stakeholders to the table (senior apartments and assisted living complexes) and invited them to work out plans that would enable them to participate in the medication delivery. Multiple meetings took place over an 18 month period to educate partners, modify plans, communicate procedures and protocols. The LHD, the County and the Municipality partnered on a Press Release prior to the full functional drill. The LHD printed 5000 flyers to be distributed to the residents of the municipality which was the full cost of the initiative, aside from staff salary costs.
Local health departments (LHD) have been charged with the monumental task of getting medication to their residents within 48 hours following a large scale biological attack. With decreasing resources and scant staff, our objectives have been to use alternate methods of distributing medication to complement the traditional POD method. In these scenarios, the most useful initiatives for the LHD are programs where the burden is shifted from the LHD to another partner. By the nature of this program, it can only be evaluated by a series of exercises, which have been completed over the past two years, culminating with a full functional exercise in June, 2018. Following each Tabletop exercise, we corrected problems that arose and changed some of the planning elements. The Full Functional Exercise tested whether the municipality could deliver medication to every residence with the 48 hour period. Additionally, we were testing communication methods for disseminating information regarding the exercise, as well as, increasing the number of residents who were enrolled in the local emergency notification system (NIXLE).
Fifty (50) local municipal employees participated in the exercise. Every residence received a delivery within 4 hours. Long Term Care and Senior Buildings were included in those 4 hours. The NIXLE system received an increase in enrollments directly following the exercise.
As a result of the successful exercise program, we are implementing the Door-To-Door program in the Phase 2 municipalities in the County. Two additional municipalities will be enrolled in February 2019.
The Door-To-Door Practice is designed with stakeholder involvement to ensure sustainability. Once the full program of exercising the plans takes place, the municipality takes majority ownership” of the program, with the LHD as a supporting partner. Because the municipal leadership is a stakeholder, the municipality is invested in its success, as well as its continued maintenance. A memorandum of Agreement (MOA) has been signed by both the LHD and the Municipality, delineating responsibilities of each partner, ensuring commitment to the initiative. Additionally, exercising the plans on a 3 year cycle increases adherence to the practice.