Giuseppe
Emeritus
ECDC Health Content - Pandemic Preparedness ? SWEDEN ? Exercise on the distribution of antiviral stockpile
Pandemic Preparedness ? SWEDEN ? Exercise on the distribution of antiviral stockpile
The exercise in November 2008 tested the distribution plans for national antiviral stockpiles in Sweden. The results suggested that the existing arrangements for distribution of medicines through established channels in Sweden were stable and comprehensive. However the exercise also demonstrated a need for further development including information flow and security.
Countries with stockpiles of antivirals and other strategic pharmaceuticals (antibiotics, vaccines) are well advised to practice how they will distribute these in a pandemic. It was against this background that the Swedish National Board of Health and Welfare (NBHW), together with the county councils of V?sternorrland and V?stra G?taland, in November of 2008 carried out an exercise to test the plan for distributing stockpiled antiviral medicines during a pandemic.
In simple terms, the distribution includes the following components:
* ?Push?? the shipment is dispatched, and allocation is based on population size and available information about the current flu.
* Shipments are delivered to one hospital pharmacy, or the equivalent, in each county council
* The health care provider orders from the hospital pharmacy, following instructions given by the county medical officer
* The county councils report back to NBHW and Welfare, stating the consumption of the delivered antivirals
* New shipments and replenishments will be issued based on reported usage, on available information about where in the pandemic cycle each county council finds itself and on prognoses regarding future needs
In the exercise only the first consignment, which in its entirety is based on a so called ?push? or allocation to the receiving county council, was included.
All parties involved, from the handler of the national stockpile to the health care provider, took part in the exercise. In the exercise actual physical distribution took place, where the shipments consisted of empty transport boxes and inner cartons, the equivalent of transport cartons and patient packets for two of the stockpiled antiviral medicines. The dispatched consignments were, however, smaller in volume during the exercise than the assumed volume during a real pandemic.
When planning the exercise it was decided to use regular transport routes where possible, and the exercise was to continue for 8 days to ensure that the consignments reached the health care providers. No work took place during the weekend.
Before the exercise started a background scenario was conveyed to the participants. The exercise was started a few hours later when NBHW made the decision to release the antiviral medicines from the national stockpiles, and to start the allocation and distribution to the county councils and the regions in accordance with the distribution plan.
Information was sent to the warehouse keeper and to the county medical officers in the two participating county councils. The warehouse keeper was then given loading instructions and quickly began to prepare delivery and to book transports. The shipment was dispatched on a Monday morning (day 2), and later that same day the consignments reached the pharmaceutical distributors, who form an intermediate link between the warehouses and the receiving hospital pharmacies. It is their task to divide the large shipments from the national stockpile into smaller consignments for the hospital pharmacies in each county council.
The hospital pharmacy at Sahlgrenska, in V?stra G?taland, received its shipment on Tuesday morning (day 3), and the hospital pharmacy in Sundsvall (V?sternorrland) received its shipment the night between Tuesday and Wednesday (day 4). A new allocation to the health care provider was made at the hospital pharmacies, in accordance with instructions from the county medical officers. The shipments reached the chosen care units in V?stra G?taland during Wednesday (day 4) and those in V?sternorrland during Thursday (day 5). The drill was completed on Friday (day 6), at which time reports on the consumption of the antivirals within the county councils had even been sent to NBHW. Once the exercise had ended, a telephone meeting was held with all the participating parties to gather the first impressions of the exercise.
Findings from the exercise showed that there was a need to work on the provision of information and that security topics needed to be on the agenda.
In December a follow-up meeting was held and every actor reported on their part in the exercise and gave their views on areas where there is a need for further development. Representatives from the Swedish Security Service were present at this meeting to offer advice and guidance, as security aspects were addressed as an important feature in the direct follow-up.
The National Board of Health and Welfare will continue to work on the issues that the exercise revealed as being clearly deficient. This work will, among other things, include preparing a tool for reporting the consumption of antivirals. Information about shipments has to be planned, specifically who needs which information, and which methods and time schedules to use to convey this information. The security questions have to be further analysed and routines put in place.
For more information regarding this initiative please contact Fredric Ripe or Anita Lundin - both members of the Swedish National Board of Health and Welfare (NBHW) - at the following e-mail addresses: Fredric.Ripe@socialstyrelsen.se - Anita.Lundin@socialstyrelsen.se
ECDC Comment (07-04-09)
Most European countries have stated publicly that they have stockpiles of antivirals for use in a pandemic.(1) Distribution of antivirals present special challenges for governments which have a responsibility to establish plans for action and counter-measures when confronted with serious events, extensive crises and threats. It is generally thought that to be effective antivirals have to be delivered at least within 48 hours of onset of symptoms if not 24 hours.(2)
In addition there are challenges that stocks will be limited and countries should not run out of antivirals. Because there are significant differences in primary care systems it will not be possible to have standard European systems and some countries are planning to reconfigure these in a pandemic.
A recent complication has been the emergence of antiviral resistance and the need to diversify stockpiles beyond simply oseltamivir. In order to ensure that these arrangements work as planned, and to get an understanding of what could be missing, it is vital to exercise and these . are important elements in the planning procedure.
1. European Parliament (ed A Trakatellis) Pandemic Preparedness in the EU: Are we sufficiently prepared? A high level policy debate June 2007
2. Halloran ME, Haydn FG, Yang Y, Longini IM, Monto AS. Antiviral effects on influenza transmission and pathogenicity: observations from household based trials. Am J Epidemiol 2007 Jan 15;165(2):212-21. Epub 2006 Nov 6
-
<cite cite="http://ecdc.europa.eu/en/health_content/phdev/090409_ph.aspx">ECDC Health Content</cite>The exercise in November 2008 tested the distribution plans for national antiviral stockpiles in Sweden. The results suggested that the existing arrangements for distribution of medicines through established channels in Sweden were stable and comprehensive. However the exercise also demonstrated a need for further development including information flow and security.
Countries with stockpiles of antivirals and other strategic pharmaceuticals (antibiotics, vaccines) are well advised to practice how they will distribute these in a pandemic. It was against this background that the Swedish National Board of Health and Welfare (NBHW), together with the county councils of V?sternorrland and V?stra G?taland, in November of 2008 carried out an exercise to test the plan for distributing stockpiled antiviral medicines during a pandemic.
In simple terms, the distribution includes the following components:
* ?Push?? the shipment is dispatched, and allocation is based on population size and available information about the current flu.
* Shipments are delivered to one hospital pharmacy, or the equivalent, in each county council
* The health care provider orders from the hospital pharmacy, following instructions given by the county medical officer
* The county councils report back to NBHW and Welfare, stating the consumption of the delivered antivirals
* New shipments and replenishments will be issued based on reported usage, on available information about where in the pandemic cycle each county council finds itself and on prognoses regarding future needs
In the exercise only the first consignment, which in its entirety is based on a so called ?push? or allocation to the receiving county council, was included.
All parties involved, from the handler of the national stockpile to the health care provider, took part in the exercise. In the exercise actual physical distribution took place, where the shipments consisted of empty transport boxes and inner cartons, the equivalent of transport cartons and patient packets for two of the stockpiled antiviral medicines. The dispatched consignments were, however, smaller in volume during the exercise than the assumed volume during a real pandemic.
When planning the exercise it was decided to use regular transport routes where possible, and the exercise was to continue for 8 days to ensure that the consignments reached the health care providers. No work took place during the weekend.
Before the exercise started a background scenario was conveyed to the participants. The exercise was started a few hours later when NBHW made the decision to release the antiviral medicines from the national stockpiles, and to start the allocation and distribution to the county councils and the regions in accordance with the distribution plan.
Information was sent to the warehouse keeper and to the county medical officers in the two participating county councils. The warehouse keeper was then given loading instructions and quickly began to prepare delivery and to book transports. The shipment was dispatched on a Monday morning (day 2), and later that same day the consignments reached the pharmaceutical distributors, who form an intermediate link between the warehouses and the receiving hospital pharmacies. It is their task to divide the large shipments from the national stockpile into smaller consignments for the hospital pharmacies in each county council.
The hospital pharmacy at Sahlgrenska, in V?stra G?taland, received its shipment on Tuesday morning (day 3), and the hospital pharmacy in Sundsvall (V?sternorrland) received its shipment the night between Tuesday and Wednesday (day 4). A new allocation to the health care provider was made at the hospital pharmacies, in accordance with instructions from the county medical officers. The shipments reached the chosen care units in V?stra G?taland during Wednesday (day 4) and those in V?sternorrland during Thursday (day 5). The drill was completed on Friday (day 6), at which time reports on the consumption of the antivirals within the county councils had even been sent to NBHW. Once the exercise had ended, a telephone meeting was held with all the participating parties to gather the first impressions of the exercise.
Findings from the exercise showed that there was a need to work on the provision of information and that security topics needed to be on the agenda.
In December a follow-up meeting was held and every actor reported on their part in the exercise and gave their views on areas where there is a need for further development. Representatives from the Swedish Security Service were present at this meeting to offer advice and guidance, as security aspects were addressed as an important feature in the direct follow-up.
The National Board of Health and Welfare will continue to work on the issues that the exercise revealed as being clearly deficient. This work will, among other things, include preparing a tool for reporting the consumption of antivirals. Information about shipments has to be planned, specifically who needs which information, and which methods and time schedules to use to convey this information. The security questions have to be further analysed and routines put in place.
For more information regarding this initiative please contact Fredric Ripe or Anita Lundin - both members of the Swedish National Board of Health and Welfare (NBHW) - at the following e-mail addresses: Fredric.Ripe@socialstyrelsen.se - Anita.Lundin@socialstyrelsen.se
ECDC Comment (07-04-09)
Most European countries have stated publicly that they have stockpiles of antivirals for use in a pandemic.(1) Distribution of antivirals present special challenges for governments which have a responsibility to establish plans for action and counter-measures when confronted with serious events, extensive crises and threats. It is generally thought that to be effective antivirals have to be delivered at least within 48 hours of onset of symptoms if not 24 hours.(2)
In addition there are challenges that stocks will be limited and countries should not run out of antivirals. Because there are significant differences in primary care systems it will not be possible to have standard European systems and some countries are planning to reconfigure these in a pandemic.
A recent complication has been the emergence of antiviral resistance and the need to diversify stockpiles beyond simply oseltamivir. In order to ensure that these arrangements work as planned, and to get an understanding of what could be missing, it is vital to exercise and these . are important elements in the planning procedure.
1. European Parliament (ed A Trakatellis) Pandemic Preparedness in the EU: Are we sufficiently prepared? A high level policy debate June 2007
2. Halloran ME, Haydn FG, Yang Y, Longini IM, Monto AS. Antiviral effects on influenza transmission and pathogenicity: observations from household based trials. Am J Epidemiol 2007 Jan 15;165(2):212-21. Epub 2006 Nov 6
-