Antiviral Distribution Control N1H1 TX

Building new partnerships, including with large retail chains, helped Texas dramatically expand its options for distributing antiviral medications during the 2009 H1N1 influenza pandemic.

The Texas Department of State Health Services (DSHS) focused on a comprehensive plan to dispense antivirals to pre-identified pharmacies, community health centers (CHCs) and Federally Qualified Health Centers (FQHCs) as a countermeasure and treatment strategy for those Texans who were un- or under-insured. The plan, called the Texas Antiviral Distribution Network, distributed more than 200,000 courses of antiviral medications from the state’s federal Strategic National Stockpile (SNS) to 1,300 locations.

For public health emergency planners, a multi-sector distribution network was the most effective distribution approach, given Texas’ geography and the urgency of getting antivirals to patients on time.

“For this type of pandemic, where you are putting out medication that needs prescription written, and you are trying to reach a large number of people over a large landmass, while trying to be effective, and efficient, I think the network model is the best system to use,” said Michael Czepiel, Deployable Teams coordinator at DSHS.

DSHS worked with all stakeholders for more than a year, Czepiel said. “We had private pharmacists throughout Texas that knew how to deal with prescription medications. We are talking about seasoned professionals here, and we figured they could do it much better than volunteers could. Setting up the typical Points of Distribution, or PODs, is labor intensive, which requires hundreds of volunteers to operate and push out the pills,” he added.

Texas purchased about half of its antiviral medications. Czepiel said the Centers for Disease Control and Prevention (CDC) provided additional courses and other medical supplies, including masks and respirators, personal protective equipment (PPE) and intravenous antibiotics.

The DSHS partnership-driven model included a combination of independent drugstores, CHCs, FQHCs, national pharmacy chains, independent pharmacies, private health providers, and small “mom and pop” operations.

Michael Poole, Texas Strategic National Stockpile Coordinator, described the steps the DSHS public health emergency planners took to make their antiviral distribution network work smoothly and without any obvious problems. He said DSHS collaborated with eight large retail pharmaceutical chains, such as Walgreens and HEB, and national retailers that offer pharmacy services, such as Wal-Mart, to get vaccines to the majority of the counties across the state, using those companies’ existing distribution systems. “The medications went to their system and they loaded them on their trucks with their normal medical and consumer products, so the cost was minimal as long as we got it to their warehouse and distribution point,” Poole said.

To reach at-risk populations in many small far-flung counties, where large chains were absent, the state signed distribution agreements with more than 90 independent pharmacies and a network of 70 community health centers and FQHCs. DSHS set up distribution hubs to send antiviral medications to one FQHC per region. Each hub then distributed courses within its region at no additional cost to the state.

Once the pharmacies received the antivirals, they had the authorization to fill prescriptions, Poole said. DSHS worked with physicians around the state to notify them of the antiviral program for those who could not afford the medication. Patients then took their prescriptions to any participating pharmacy and received the vaccine for a $10 dispensing fee. Additionally, a system was put into place that allowed the pharmacies to waive the $10 dispensing fee to those who could not afford it.

DSHS distributed more than 200,000 courses. Pharmacies actually dispensed approximately 30,000 of those courses, Czepiel added.

Despite their rigorous efforts and a number of successful partnerships, state planners acknowledged that there were problems reaching many people who could not afford to go to the doctor or did not have a doctor on record.

“How did they get antivirals?” SNS coordinator Poole asked. “Well, they received them from the emergency room; the emergency room doctors were part of the plan and filled prescriptions and the medication was dispensed from the State Stock.”

A cumbersome contract process created additional challenges in distributing antivirals to a number of independent pharmacies, Czepiel noted. “We did not have that problem in the spring because then we were operating under emergency orders,” he added.

There are several benefits to developing a statewide distribution network. Czepiel recommended people start planning long before an emergency. He said legal and contract experts should look at a distribution system before it goes online to avoid delays.

Both Czepiel and Poole said the antiviral distribution plan is a proven method and is easily replicable. “I would suggest that anyone who wants to do a system like what we did, start working on it while you don’t have a pandemic, get your contract in place, have everything together that you have to do, legally,” Czepiel said.

Building such a network is just the first step. Czepiel pointed out that sustaining the networks also requires time, money, and commitment. Nonetheless, the benefits of such a distribution system are obvious beyond the borders of Texas, Czepiel added. Five other states have already adopted the Texas plan, and Wal-Mart uses it as a model to deal with other states for emergency preparedness.

“It was effective for us,” Poole said. “If we had a pandemic next week, we will just pull out our distribution plan, dust it off, and use it again.”