Appendix G: Evaluation of the National Emergency Stockpile System (NESS) – International studies

Background^{[Link to footnote K]}

In 1999, the United States Congress tasked the Department of Health and Human Services (DHHS) and the Centers for Disease Control and Prevention (CDC) with the establishment of a national pharmaceutical stockpile system, after March 2003 referred to as the Strategic National Stockpile (SNS).[Link to footnote L] Congress supports CDC's public health preparedness and response activities.

The CDC's Office of Public Health Preparedness and Response manages two programs:

• Public Health and Emergency Preparedness (PHEP) Cooperative Agreement

  CDC's PHEP cooperative agreement funds 62 state, locality and U.S.-insular-area public health departments to build and strengthen their ability to respond effectively to public health emergencies. The PHEP cooperative agreement funding includes support for the Cities Readiness Initiative of the SNS. This program focuses on enhancing preparedness for responding to a large-scale bioterrorist event within 48 hours in the nation's largest cities and metropolitan statistical areas, where more than half of the U.S. population resides.

• Strategic National Stockpile (SNS)

  The SNS program is managed by the DHHS. CDC's Division of Strategic National Stockpile (DSNS) operates and maintains the SNS.

  The core mission of the SNS is to "deliver critical medical assets to the site of a national emergency,"^{[Link to footnote M]} specifically guaranteeing the delivery of "12-Hour Push Packages" within 12 hours of the federal decision to deploy.^{[Link to footnote N]}

  DSNS is responsible for:^{[Link to footnote O]}

  • creating pathways to move the materiel to the area of need in the timeframe that is clinically relevant
  • assuring integration with local planning (medical response is local)
  • providing technical assistance to assure that all localities, states and federal agencies funded by the PHEP cooperative agreement have plans in place to receive, stage, store, distribute and dispense medical assets from the stockpile as well as other sources^{[Link to footnote P]}
  • maintaining materiel in a manner that assures viability.

  While the mandate is essentially domestic, the CDC/SNS have responded internationally when required, according to federal policy decisions. In addition, the U.S. government has commitments to the World Health Organization (i.e. the International Health Regulations).

What is the SNS?

The SNS is a network of strategically located storage facilities. The stockpile represents a real, material asset in federal warehouses, which can be quickly activated to meet the country's needs during a crisis.[Link to footnote Q]

The SNS maintains ownership of the inventory and is responsible for storing, monitoring and maintaining the inventory, which is located in secure, environmentally controlled areas throughout the United States.^{[Link to footnote R]} CDC currently maintains several large secure warehouses across the country, as well as an undisclosed number of smaller facilities nationwide.

The SNS is not intended as a first response tool; it is designed to supplement and re-supply state and local public health departments in the event of a national emergency anywhere and at any time within the United States or its territories.[Link to footnote S],[Link to footnote T]

What is in the stockpile?

The SNS contains a portfolio of antibiotics, medical supplies, chemical antidotes, antitoxins, antivirals, vaccines and other pharmaceuticals.^{[Link to footnote U]} Since the SNS was created, medicines and medical supplies to fight against pandemic flu have been added, including antivirals, respirators, masks and gloves.^{[Link to footnote V]} It should be noted that the SNS does not stock social service supplies.^{[Link to footnote W]}

Materials in the stockpile are standardized, i.e. number and type. The stockpile contains:^{[Link to footnote X]}

• 12-Hour Push Packs (less than 5% of the SNS inventory), including
  • broad-spectrum oral and intravenous antibiotics
  • other medicines for emergency conditions
  • intravenous fluids and fluid administration kits
  • airway equipment, such as endotracheal tubes, stylettes, oropharyngeal airways, Ambu-Bags and CO₂ detectors
  • bandages.
• managed inventories maintained by the SNS or by specific vendors or manufacturers, including:
  • vaccines
  • antitoxins (e.g. botulinum)
  • ventilators^{[Link to footnote Y]}
  • additional quantities of 12-Hour Push Pack items.
• agents in the stockpile that could be used for medical problems related to radiological or nuclear events, including
  • chelating agents: calcium and zinc DTPA
  • Prussian blue
  • potassium iodide
  • growth factors / cytokines for white blood cells.

The SNS also has temporary equipment sets referred to as Federal Medical Stations (FMS).^{[Link to footnote Z]} An FMS is a cache of medical supplies and equipment that can be used to set up a temporary, non-acute medical care facility. Each FMS has beds, supplies, and medicine to treat 250 people for up to three days. Most of the items in the set are expendable, with only a few recoverable items. A 250-bed FMS consists of three modules:

• Base Support: administrative, food service, housekeeping, basic medical supplies, and personal protective equipment; there are five-bed units, with 50 beds each
• Treatment: medical/surgical items
• Pharmacy: medications.

In addition, in 2004 CDC established CHEMPACK, a voluntary participation project for the "forward placement" of sustainable repositories of nerve agent antidotes in numerous locations throughout the United States, so that they are immediately accessible for the treatment of affected persons. Under this project, the SNS:

• maintains ownership of the CHEMPACK stockpile
• in conjunction with state and local officials, places the antidotes in numerous strategically placed containers under controlled and monitored storage conditions for use in the event of an emergency involving nerve agents
• implements strategies to maximize the shelf life of the antidotes to minimize re-procurement costs and maintain quality, specifically through the Federal Drug Administration's Shelf Life Extension Program.[Link to footnote AA]

CDC's CHEMPACK program has been fielded in all states and has placed over 1,900 containers of nerve agent antidotes.[Link to footnote BB]

How does CDC respond to requests?

The plan is to deliver critical medical resources to the site of a national emergency when local public health resources would likely be or have already been overwhelmed by the magnitude of the medical emergency.

Pre-event requests for SNS resources might include:

• actionable intelligence indicating an impending chemical, biological, radiological/nuclear, or large explosive attack or overwhelming public health disaster
• analysis of data derived from syndromic or epidemiologic surveillance
• a sentinel event, such as a single case of smallpox.

Leading up to or following an incident, assets of the SNS can be requested by:

• state departments of health, usually in conjunction with the state governor. To receive SNS assets, the affected state's governor's office would directly request deployment of SNS assets from DHHS/CDC, or as part of a formal request for federal assistance through the national emergency response system (DHHS).[Link to footnote CC]
• national agencies, e.g. the Federal Emergency Management Agency, the Federal Bureau of Investigation, in certain circumstances.

Requests are evaluated by the director of the CDC and the secretary of DHHS, and the SNS will be deployed if local resources are deemed insufficient. The CDC will assume the lead in deploying the SNS for local use, but coordination with the Department of Homeland Security may be required at times. In such instances, the two organizations will work together to evaluate the request and the situation and to determine a prompt course of action; if deployment is agreed upon, the assets that are most appropriate will be released.[Link to footnote DD]

At the same time as assets from the SNS are deployed, the SNS program can deploy teams to provide on-site technical assistance and coordinate with state and local officials. In this way, SNS assets can be efficiently received and distributed on arrival at the site.^{[Link to footnote EE]} The decision to deploy is a collaborative effort between local, state and federal officials. States can request SNS assets when state and local public health systems become overwhelmed and local supplies are depleted or commercially unavailable.^{[Link to footnote FF]}

The first line of support lies with the immediate-response 12-Hour Push Package. DSNS refers to the push packages as its "core offering," essentially a "one-size-fits-all" package. State and local first responders and health officials can use the SNS to bolster their response to a national emergency with a 12-Hour Push Package, Managed Inventory (MI) or a combination of both, depending on the situation. These caches of pharmaceuticals, antidotes and medical supplies are designed to provide rapid delivery of a broad spectrum of assets for an ill-defined threat, in the early hours of an event.^{[Link to footnote GG]} The push packages are positioned in strategically located, secure warehouses ready for immediate deployment to a designated site within 12 hours of the federal decision to deploy SNS assets.

"The SNS has been supplemented by a second tier of medical products that are under the control and management of selected, pre-qualified vendors."^{[Link to footnote HH]} If the incident requires additional pharmaceuticals and/or medical supplies, follow-on MI supplies will be shipped to arrive within 24 to 36 hours. If the agent is well defined, the MI can be tailored to provide pharmaceuticals, supplies and/or products specific to the suspected or confirmed agent(s). In this case, the MI could act as the first option for immediate response from the SNS program.^{[Link to footnote II]}

When required, the SNS also deploys Federal Medical Stations.^{[Link to footnote JJ]} These standardized caches of medical supplies and equipment are temporary, non-acute medical care facilities used primarily as shelters for seniors, children, persons with disabilities, etc.

How does the delivery system operate?^{[Link to footnote KK]}

Push packages are positioned in strategically located, secure warehouses ready for immediate deployment to a designated site within 12 hours of the federal decision to deploy SNS assets.

The 12-Hour Push Packages have been configured to be immediately loaded onto either trucks or commercial cargo aircraft for the most rapid transportation. Concurrent to SNS transport, the SNS program will deploy its Stockpile Service Advance Group (SSAG). SSAG staff will coordinate with state and local officials so that SNS assets can be efficiently received and distributed upon arrival at the site.^{[Link to footnote LL]}

What training is offered?

At the request of user organizations, CDC provides DVDs for training for the use of ventilators.

CDC also partners with organizations to offer webcast training. For example, in 2009 the CDC and the American Association of Respiratory Care partnered to offer a webcast training module to show doctors and first responders how to best use the LTV 1200 ventilator in an emergency. The webcast provides information on how to use the ventilator for patients with serious breathing problems caused by the H1N1 influenza virus.^{[Link to footnote MM]}

In order to help states prepare to manage, distribute and dispense SNS materiel during a public health emergency, a satellite broadcast presentation is available on the planning components (and is also available on DVD). In addition, the CDC recently started releasing podcasts on how to prepare for Technical Assistance Reviews (TARs), and other DVDs are currently in production to orient viewers on the SNS.

Classroom training on a variety of topics is provided in Atlanta and in the field. Field courses are developed with state planners to customize the content to support the state's plans.

How are assets managed?

CDC is the only occupant of SNS facilities. To determine and review the composition of SNS program assets, HHS and CDC consider many factors, such as current biological and chemical threats, the availability of medical materiel, and ease of dissemination for pharmaceuticals. One of the most significant factors in determining SNS composition, however, is the medical vulnerability of the U.S. civilian population.^{[Link to footnote NN]}

The SNS program ensures that the medical materiel stock is rotated and kept within potency shelf-life limits. This involves quarterly quality assurance/quality control checks on all 12-Hour Push Packages; annual 100% inventory of all 12-Hour Push Package items; and inspections of environmental conditions, security and overall package maintenance (i.e. efficiently received and distributed on arrival at the site).[Link to footnote OO]

Agreements with vendors provide that SNS owns the product, the operations are "turn-key" and CDC will have 24-hour access. Vendors have their own inventory management systems that must be compliant with current good manufacturing practices (CGMP).

Each state is responsible for ensuring all localities within its borders are prepared to manage, distribute and dispense SNS materiel during a public health emergency.[Link to footnote PP] To help ensure readiness, there is a CDC DSNS program services consultant in each state, who works closely with the state SNS coordinator to review SNS programs on an annual basis.[Link to footnote QQ] The state's SNS coordinator gathers all materials for review using a Technical Assistance Review Tool Users Guide and other evaluation-readiness scoring. Thirteen key elements are considered: developing an SNS plan; requesting SNS assistance; managing SNS operations; tactical communications; public information and communications; security; receiving, staging and storing; controlling inventory; repackaging; distribution; dispensing; hospitals and alternate care facilities coordination; and training, exercising and evaluating.

The U.S. Department of Veterans Affairs (VA) supports several federal stockpiling programs because of its "existing national infrastructure and economical purchase prices."^{[Link to footnote RR]} The VA:

procures, stores, rotates, and manages pharmaceutical caches, strategically located throughout the country, to support the DHS National Medical Response Teams. In addition, the VA has an agreement with the Army Corps of Engineers to purchase and store a Congressional cache (activated following the anthrax letter attacks in the fall of 2001). The VA supports other entities by purchasing and storing pharmaceuticals, (e.g., Federal Bureau of Investigation and some Metropolitan Medical Response System caches for cities in the highest-risk areas). These caches are geared towards treatment of patients exposed to chemical, biological, and/or radiological agents, or high explosive events.^{[Link to footnote SS]}

Background

The Australian government formally established the National Medical Stockpile (NMS) in 2002. Emergency planning involving stockpiling started in the early 2000s in preparation for the Olympic Games in Sydney and was further precipitated by the events of September 11, 2001 in the United States.

Since 2004, in preparation for the next anticipated pandemic, the Department of Health and Ageing (DHA) has had a standing contract with vaccine manufacturers for the rapid development and supply of a pandemic vaccine,^{[Link to footnote TT]} antiviral agents and personal protective equipment (PPE).^{[Link to footnote UU]}

In 2009, emergency preparedness and response concentrated on dealing with the threat of the H1N1 influenza. In response, DHA purchased 21 million doses of the H1N1 vaccine from CSL Limited, based on coverage of 50 percent of the Australian population assuming a two-dose regime.^{[Link to footnote VV]}

What is the NMS?

The NMS is a national strategic reserve of essential vaccines, antibiotics, antiviral drugs, chemical and radiological antidotes, and PPE.

How is the NMS governed?

In June 2006, the Australian Health Ministers' Advisory Council (AHMAC) established the Australian Health Protection Committee (AHPC). The Committee is made up of state and territory Chief Health Officers, disaster health experts and other subject matter experts.

The AHPC provides advice to AHMAC on Australia's preparedness for health emergencies and approaches to coordinate the national response to significant incidents and to address any deficits.

The Health Emergency Management Branch (HEMB), Office of Health Protection, within the DHA, is responsible for managing the NMS, including inventory management, planning and developing Memoranda of Understanding with states and territories for deployment of the stockpile.

The role of HEMB is to provide "effective risk assessment and coordination of national health responses to naturally occurring or deliberately introduced biological and emerging threats to the population" and to coordinate the health sector's response to whole-of-government emergency management response activities.[Link to footnote WW]

The Branch also provides strategic advice to the AHPC and has been used as a forum to share best practices through its subcommittee and special advisory committees/groups. For example, special committees include an "all-hazards" working group of medical experts, including a chemical, biological and radio-nuclear (CBRN) technical panel, where experts are able to exchange information.

What are the roles of partners?

Every state and territory has its own stockpile, including an inventory of antiviral agents. Australia's planning and response to pandemics relies on partnerships between the DHA and its state and territory counterparts.[Link to footnote XX]

The Australian Red Cross Society is a major partner in responding to disasters in Australia. The DHA provided $5 million to the society in 2009-10 to support a broad range of health-related humanitarian work and community activities, including disaster preparedness, first aid, disaster response and refugee services, and the society's work in the Asia-Pacific region.[Link to footnote YY]

What is in the stockpile?

The NMS provides a key reserve of essential medicines and equipment to protect Australians from the effects of chemical, biological and radiological terrorism or a major communicable disease outbreak.

The stockpile is designed to supplement existing medical stocks kept in the Australian hospital system, to ensure that medical supplies do not run low in response to an incident in Australia. It also includes specialized medical supplies, such as the nation's stock of smallpox vaccine.

The NMS does not stock social service supplies. The Australian Red Cross Society is funded by the Australian government and states and territories to provide social service supplies for both domestic and international emergency response.

The Department of Families, Housing and Community Services and Indigenous Affairs provides funding to non-governmental organizations for emergency relief and recovery arrangements that are provided locally.^{[Link to footnote ZZ]}

How does the delivery system operate?

The NMS is kept in various strategic locations around Australia. Specific details of the stockpile's contents are not publicly released for security reasons.

All jurisdictions possess a pharmaceutical stockpile separate from the NMS and all jurisdictions maintain stockpiles of PPE for responding to a CBRN health disaster or pandemic influenza. This is confirmed by the National Health Disaster Management Capability Audit 2008, released March 23, 2010, which states: "All jurisdictions have undertaken assessments of hospital embedded stocks and/or manufacturer stockholdings. At the time of survey completion, most states and territories reported Oseltamivir (Tamiflu) stockpiles. Three States (Victoria, Queensland and South Australia) also reported Zanamivir (Relenza) stockpiles."^{[Link to footnote AAA]}

Australian state and territory authorities have constitutional responsibility, within their boundaries, for coordinating and planning for response to disasters and civil emergencies. When the total resources (government, community and commercial) of an affected state or territory cannot reasonably cope with the needs of the situation, the state or territory government can seek assistance from the Australian government.^{[Link to footnote BBB]}

The Australian Department of Defence has its own supplies in place. The Attorney‑General's Department and other central agencies are interested in the stockpile from a national security and budget or funding perspective.

The Australian Customs and Border Protection Service and the Department of Agriculture, Fisheries and Forestry have limited PPE supplies for the protection of their own staff and draw on the NMS if required.

The DHA works closely with other agencies within the Australian government, state and territory health departments, and is supported by Aboriginal and Torres Strait Islander health organizations to achieve equality in health status and life expectancy for Aboriginal and Torres Strait Islander peoples.

How does the DHA respond to requests?

Commentaires sur les écarts : S.O.

Résultats attendus et résultats obtenus pour 2013-2014 :

RA 1.1 : En matière de santé publique, les décisions et les interventions sont fondées sur des services d’analyse de référence accrédités, rapides et fiables permettant de dépister avec exactitude toutes les souches du VIH en circulation au Canada et d’orienter les efforts vers toute nouvelle éclosion de VIH. Ceci permet de déterminer et de dépister de façon efficace les nouvelles souches de VIH et d’améliorer la qualité, la fiabilité et la comparabilité des tests de dépistage du VIH.
RO 1.1 : Durant le déménagement des Laboratoires nationaux du VIH et de rétrovirologie à Winnipeg, l’Agence a effectué des analyses en parallèle dans ses laboratoires d’Ottawa et de Winnipeg pour satisfaire aux exigences de qualité de l’ISO concernant les délais de production de rapports sur les analyses de référence et maintenir son accréditation.

RA 1.2 : L’utilisation des connaissances générées par les laboratoires est renforcée en vue d’établir des normes relatives au diagnostic, au pronostique et aux essais sur la résistance aux médicaments; d’offrir des services d’assurance de la qualité et de normalisation du rendement aux laboratoires régionaux; de déterminer les changements dans les tendances relatives à la transmission du VIH; et de réduire la transmission du VIH de la mère à l’enfant par l’entremise de la désignation des thérapies antivirales optimales et abordables. Les plateformes d’expertise et de connaissances quant à la recherche en laboratoire sont consolidées afin d’établir un centre de leadership mondial en matière de recherche sur le VIH, de diagnostic viral, d’intervention en cas d’éclosion et de liens génétiques quant au risque de contracter la maladie.
RO 1.2 : L’Agence a contribué aux analyses et aux essais en laboratoire pour guider les études sur les pratiques exemplaires en matière d’allaitement et réduire la transmission du VIH de la mère à l’enfant, un objectif important de l’Organisation mondiale de la Santé (OMS) dans la prévention du VIH. Les études comprenaient l’évaluation du rôle de facteurs propres à l’hôte, comme la santé maternelle et les pratiques d’allaitement, dans la prévention de la transmission du VIH par le lait maternel.

L’Agence a mis au point des techniques de séquençage de nouvelle génération pour les analyses de résistance aux médicaments contre le VIH à titre de pratique exemplaire et a commencé à promouvoir ces nouvelles techniques auprès de ses partenaires nationaux et internationaux. De plus, elle a fourni une expertise et une aide techniques en évaluant les taux de VIH auparavant indétectables dans le sang de nourrissons infectés, dans le cadre de l’initiative de recherche d’un traitement contre le VIH chez les enfants. Celle-ci a pour but de trouver un traitement fonctionnel^{Note de bas de page 7}  pour les enfants qui sont nés avec le VIH.

De plus, l’Agence a fourni des services externes d’assurance de la qualité à plus de 900 laboratoires de partout dans le monde, ce qui a eu des effets positifs sur les soins et les traitements que reçoivent des milliers de personnes infectées par le VIH. Grâce à l’ouverture du Centre de recherche en infectiologie JC-Wilt en février 2014, l’Agence a consolidé ses services de laboratoire nationaux sur le VIH afin de mieux servir les intervenants cliniques et le milieu de la recherche sur le VIH.

RA 2.1 : Faire participer et collaborer les provinces et les territoires par l’entremise du Réseau de santé publique, établir une meilleure connaissance des tendances et une meilleure compréhension des facteurs associés au VIH et aux ITSS à l’aide d’enquêtes épidémiologiques ciblées sur le comportement, et promouvoir et intégrer des pratiques exemplaires afin de contribuer aux efforts de prévention et de contrôle dans les activités de surveillance et d’orientation sur le VIH et les ITSS connexes.
RO 2.1 : L’Agence a collaboré activement avec les provinces et territoires, par l’entremise du Comité directeur sur les maladies transmissibles et infectieuses du Réseau de santé publique qui a formé un groupe de travail ponctuel chargé de définir les domaines possibles de collaboration FPT pour prévenir et contrôler les ITSS. En collaboration avec les provinces et territoires, l’Agence a poursuivi ses activités de surveillance qui comprenaient l’amélioration de la collecte de données à Québec (sur les utilisateurs de drogues injectables) et à Montréal (sur les personnes originaires de pays où le VIH est endémique) et la promotion des résultats de son système de surveillance améliorée qui a été mis à l’essai chez les Autochtones, les utilisateurs de drogues injectables et les jeunes. L’Agence a utilisé des webinaires pour promouvoir ses principaux rapports de surveillance et d’orientation en santé publique, comme le rapport intitulé Le VIH et le sida au Canada : Rapport de surveillance en date du 31 décembre 2012 et le Guide pour le dépistage et le diagnostic de l’infection par le VIH. Les résultats de ses activités de surveillance améliorée ont été diffusés à environ 1300 professionnels de la santé publique de première ligne, experts médicaux, travailleurs communautaires et partenaires provinciaux et territoriaux, qui ont indiqué leur intention d’appliquer ces données ou ces directives dans leur travail.

L’Agence a examiné les données sur les risques de la transmission du VIH et a élaboré des outils d’application des connaissances sur les souches de gonorrhée résistantes aux médicaments. Le but de cette initiative était de mieux faire connaître les nouvelles recommandations de traitement contre les infections gonococciques et de favoriser leur adoption, de manière à réduire le développement et la propagation de la résistance aux antimicrobiens. L’Agence a également diffusé le chapitre révisé sur les infections gonococciques des Lignes directrices canadiennes sur les infections transmissibles sexuellement et  amorcé la mise au point d’une application mobile sur la prévention et le contrôle de la gonorrhée multirésistante et d’autres infections transmissibles sexuellement.

RA 3.1 : Améliorer la capacité en santé publique et la capacité communautaire afin de prévenir et de contrôler le VIH et les ITSS connexes, par l’entremise de partenariats stratégiques auprès d’intervenants.
RO 3.1 : L’Agence et la Banque mondialeont élaboré des documents de sensibilisation et les ont diffusés à 140 intervenants canadiens qui participent aux interventions de lutte contre le VIH/sida, dont des dirigeants communautaires, des décideurs et des chercheurs universitaires. Ces mesures de sensibilisation ont permis de cerner des mécanismes et des méthodes pour évaluer les interventions de même que les pratiques exemplaires et prometteuses.

L’Agence, le ministère de la Santé et des Soins de longue durée de l’Ontario et le Réseau ontarien de traitement du VIH ont tenu la Journée annuelle d’application et d’échange des connaissances à laquelle participent des organismes communautaires. Cette activité a permis d’améliorer la capacité des organismes communautaires de prévenir et de contrôler le VIH par l’échange de pratiques éprouvées, la définition des tendances régionales, des possibilités de réseautage et le renforcement des partenariats régionaux. L’une des tendances observées est le « grisonnement » de la population atteinte du VIH (personnes atteintes âgées de 40 ans et plus), qui constitue un nouveau défi pour les organismes communautaires.

L’Agence a appuyé Santé, Vie saine et Aînés Manitoba en participant aux travaux du comité consultatif de la stratégie de la province sur les infections transmissibles sexuellement et les pathogènes à diffusion hématogène.

Elle a continué de coprésider le Community HIV Policy and Funding Consortium de l’Alberta avec le ministère de la Santé de l’Alberta. Elle a appuyé la participation active de représentants communautaires et aidé à renforcer les capacités en matière d’épidémiologie des maladies infectieuses et à élaborer une stratégie sur le VIH/sida en milieu communautaire à l’intention des Autochtones de l’Alberta.

Enfin, l’Agence a fourni du financement pour appuyer la mise sur pied du conseil autochtone de la Saskatchewan sur le VIH/sida afin de faciliter l’élaboration de la stratégie de la province sur le VIH/sida chez les Autochtones.

RA 3.2 : Élaborer des approches intégrées quant au VIH et aux ITSS connexes et aux facteurs comme les comorbidités, la santé mentale, les maladies chroniques et autres déterminants de la santé, dont un modèle de financement communautaire intégré et une stratégie renouvelée de mobilisation des intervenants qui élargit le mandat des mécanismes actuels de mobilisation axés sur des maladies précises.
RO 3.2 : L’Agence a mobilisé les intervenants pour élaborer les principes directeurs et les principales priorités relativement à l’établissement, d’ici le 1er avril 2017, d’un nouveau fonds d’action pour lutter contre le VIH/sida et l’hépatite C. Elle a également examiné les structures de gouvernance externes actuelles de la société civile, comme les organismes communautaires, pour lutter contre le VIH/sida, l’hépatite C, les infections transmissibles sexuellement et les facteurs de santé connexes et a collaboré activement avec les membres de celle-ci.  

RA 3.3 : Améliorer les renseignements offerts aux intervenants en santé publique en fournissant des connaissances à jour en vue d’interventions efficaces auprès des populations vulnérables, dont les rapports d’étape sur le VIH/sida et les populations distinctes, des questions et réponses sur les pratiques d’inclusion dans l’éducation en matière de santé sexuelle auprès des minorités raciales et ethniques, des questions et réponses sur les ITSS chez les adultes d’âge moyen et les adultes âgés, et autres produits d’information ciblés.
RO 3.3 : L’Agence a publié une version révisée de la brochure sur les infections transmissibles sexuellement à l’intention des jeunes, dont plus de 100 000 exemplaires sont distribués au public chaque année. L’Agence a également publié des questions et réponses sur les pratiques d’inclusion dans la prévention des ITSS chez les minorités ethnoculturelles et le Rapport d’étape sur les populations distinctes : VIH/sida et autres infections transmissibles sexuellement et par le sang parmi les jeunes au Canada. On a fait la promotion de ces ressources et d’autres rapports d’étape dans le cadre de webinaires auxquels plus de 500 intervenants en santé publique ont participé, y compris des travailleurs communautaires de première ligne et des représentants provinciaux et territoriaux, et les documents ont été téléchargés 7 245 fois.

Des organismes communautaires bénéficiaires de subventions et de contributions de l’Agence, comme le Positive Women’s Network, ont offert de la formation sur le VIH, l’hépatite C et la santé sexuelle à des fournisseurs de services et de soins de santé. Grâce au financement de l’Agence, le Centre de santé communautaire Klinic de Winnipeg a produit un manuel du fournisseur de services dans le cadre du programme Teen Talk pour aider les fournisseurs de services de la région du Nord qui travaillent auprès des populations vulnérables dans les domaines de la santé sexuelle, des relations saines et de la santé mentale.

Grâce au soutien financier de l’Agence, Action Santé Travesti(e)s et Transsexuel(le)s du Québec (ASTTQ) a offert des ateliers de sensibilisation à 100 professionnels et étudiants des domaines de la santé et des services sociaux ainsi qu’à des organismes de services liés au sida sur les besoins en santé des transgenres. ASTTQ a également mis à jour son guide à l’intention des fournisseurs de services, qui a été distribué dans les deux langues officielles à l’échelle de la province de Québec.

According to the AHPC's National Health Disaster Capability Audit 2008:

Current Australian health sector response arrangements dictate that, depending on the scale and nature of a presenting emergency, the health sector response may involve local, regional, state and national tiers of response. Surge theory and practice proposes that, as the resources of each tier become overwhelmed, response elements of the next tier are utilised. Medical surge is therefore a complex concept with many variables that influence capacity and capability across all tiers of the Australian health sector.^{[Link to footnote CCC]}

In terms of surge capacity, it is the role of states and territories to maintain all trauma and hospital services. The Australian government provides national coordination of acute care information, i.e. information sharing on vulnerabilities.

If there is an event of "national consequence" (e.g., two or more jurisdictions are affected, or a plane crashes in an urban area) then the Australian government coordinates the movement of patients and medical assistance teams. If a jurisdiction is overwhelmed, the Australian government will work with states and territories to coordinate the movement of assets.

In terms of CBRN antidotes, states and territories have limited capacity, and the Australian government is called upon to assist.

During the H1N1 pandemic (2009), states and territories did not have enough antiviral agents, in particular to meet paediatric requirements; therefore, it was decided that the NMS would buy and store these medicines and provide them to the states and territories as required.

How are needs assessed?

Decisions to use the NMS are based on both internal and external expert clinical advice and on threat and risk assessment from the Australian National Security Agency.

The budget for the NMS is determined by the Australian government as part of its annual budget process.

The CBRN committee, which meets on a regular basis, includes the NMS on the agenda as a standing item. Other work of the committee includes reviewing the stockpile each quarter; horizon scanning for the Executive; and meeting with representatives from pharmaceutical companies. The National Expert Advisory Committee meets at the same time.

In terms of detection assistance, the Australian government provides a budget to help state and territory laboratories detect threats, for instance, by providing quick diagnostics for influenza and to detect certain chemical agents.

The Australian government funds the Defence Science Technical Organisation that researches chemical warfare agents.

Current issues

There is currently a strategic review to look at how the NMS has been managed over time. A reference group has been established to review the final report and provide strategic advice.^{[Link to footnote DDD]} Areas of consideration include:

• management of the NMS, in particular future responsibility for procurement outside of the bureaucracy
• stock rotation (by states and territories, medical sphere) and market issues.

Current discussions

There have been quadrilateral discussions with the United Kingdom, the United States and Canada on CBRN emergency management.

Background^{[Link to footnote EEE]}

The Norwegian Emergency Preparedness Stockpile System (NOREPS) was established as an ad hoc initiative in the aftermath of the 1991 Gulf War.

There were two forces driving creation of NOREPS: Norway's policy of supporting the lead role of the United Nations in humanitarian response; and political interest in flagging Norway as a major humanitarian actor.[Link to footnote FFF]

What is NOREPS?

The mandate of NOREPS, formally adopted in February 2000, outlines three objectives:

• to provide a system of preparedness to quickly meet immediate humanitarian needs in sudden crises
• to provide goods and services in the initial phase of crisis, for which the goods and services are appropriate, competitive and quality ensured
• to provide a contribution to a strengthened international coordinated crisis response.

The NOREPS system enables pre-packed products to be airborne within 24 hours and service packages and trained personnel to be on site within 72 hours.

How is NOREPS governed?

The Norwegian Ministry of Foreign Affairs (MFA) has the lead position as initiator. The public entity, Innovation Norway, is the administrator of the system.^{[Link to footnote GGG]} Innovation Norway is in charge of marketing, processing requests for in-kind donations, getting quotations for supplies and transportation, and presenting this information to the MFA for its decision.

Non-governmental organizations associated with NOREPS include:

• CARE Norge
• Norwegian Church Aid
• Norwegian People's Aid
• The Norwegian Red Cross
• The Norwegian Refugee Council
• Save the Children Norway.

A government agency, The Directorate for Civil Protection and Emergency Planning (DCPEP), is also associated with NOREPS.

Commercial members, a select group of Norwegian suppliers of goods and services,[Link to footnote HHH] pay for membership in NOREPS. Suppliers' products must go through a qualification process with the NOREPS system.

The network of partners is guided by a Member Meeting, a Working Group and an Advisory Group. New members and products must go through a qualification process, i.e. quality clearance, and must be approved by the Working Group.

What is in the stockpile?

NOREPS consists of three main components:^{[Link to footnote III]}

• goods from stockpiles or as in-kind donations. The NOREPS catalogue contains 75 different products for the relief market, from a total of 12 commercial suppliers. The products have all been vetted by the NOREPS system.
• NORSTAFF, an emergency staff roster system (and regional variants)
• service packages, which are made up of the equipment needed, as well as the installation and, if required, the staff to manage them. Service packages may be provided as deemed appropriate by the following organizations:
  • DCPEP: Norwegian Support Teams
  • Norwegian Church Aid (NCA): Emergency Water and Sanitation Preparedness Package
  • Norwegian Red Cross: Health Services Preparedness Package
  • Norwegian People's Aid: Mine Clearance Preparedness Package.

Service packages are self-contained modules with both the equipment and staff to carry out a particular function. The 2008 Evaluation of the Norwegian Emergency Preparedness System indicated that three of the service packages had been widely used:^{[Link to footnote JJJ]}

1. Norwegian Hospital (NORHOSP) is provided by the Norwegian Red Cross when deemed appropriate; the main clients are the International Committee of the Red Cross and the International Federation of Red Cross and Red Crescent Societies. NORHOSP is a module-based hospital centered on a surgical module. Prior to 2008, there was one complete NORHOSP set held in stock by the Norwegian Red Cross; Norway held another five sets for domestic emergencies. In the past, the domestic sets have been loaned out for international response.
2. Base camp packages are provided by DCPEP in support of the United Nations. At present, the World Food Programme (WFP) is the largest customer for base-camp packages.
3. The NCA water and sanitation package had been used within the Action by Churches Together (ACT) network on numerous occasions.

In terms of value, the 2008 evaluation of NOREPS reported that, in 2005, goods worth 428 million Norwegian kroner (NOK) were sold through NOREPS, with the MFA financing 30% of the cost and the requesting organizations covering the rest. Between 2001 and 2005 (excluding 2005), the 22 companies participating in NOREPS sold goods for approximately 1.3 billion NOK.^{[Link to footnote KKK]}

How does the delivery system operate?

NOREPS partner companies commit to stock approved products and to delivery to an international airport from their own premises in Norway within 24 hours of request.

NOREPS suppliers hold their stocks at a variety of locations, with the largest stock held in their own premises in Norway. Several suppliers are located near Gardermoen Airport.^{[Link to footnote LLL]}

The main depots are located in Norway, Brindisi (Italy) and Dubai with the United Nations Humanitarian Response Depot (UNHRD). A wide range of products is kept at each depot to enable the efficient and cost-effective dispatch of a range of vital items at the same time.

The related parts of NOREPS work independently of each other.^{[Link to footnote MMM]}

What are the lessons learned?

The 2008 evaluation of NOREPS reported that service packages could be more useful if they had been designed as smaller, more flexible modules. For example, the large size of a full NORHOSP made it too slow to deploy and too costly in terms of operating costs.^{[Link to footnote NNN]}

The evaluation also found that the nearer stocks are to a crisis site, the more effective they are at saving lives and preventing suffering. However, it noted, this advantage must be balanced against the cost of maintaining stocks at a lot of different locations and the longer turnover period. All items have a limited shelf life and are subject to deterioration in storage.^{[Link to footnote OOO]}

The 2008 evaluation indicated that individuals with significant emergency experience stressed the importance of stockpiles as a way of facilitating quick responses to humanitarian crises:^{[Link to footnote PPP]} "Good procurement cannot replace stockpiling because of the lead times involved in production of procured items."^{[Link to footnote QQQ]}