Computer-Aided DesignComputer-Aided DesignNathaniel Hupert, M.D., M.P.H.Nathaniel Hupert, M.D., M.P.H.

Assistant Professor of Public Health and MedicineAssistant Professor of Public Health and MedicineDivision of Outcomes and Effectiveness ResearchDivision of Outcomes and Effectiveness ResearchWeill Medical College of Cornell UniversityWeill Medical College of Cornell University

Guiding QuestionsGuiding Questions

What are the critical components of a What are the critical components of a mass vaccination campaign?mass vaccination campaign?What role can spreadsheet models play in What role can spreadsheet models play in forecasting resource requirements for forecasting resource requirements for mass vaccination campaigns?mass vaccination campaigns?What are the limitations of computer What are the limitations of computer modeling in developing mass vaccination modeling in developing mass vaccination plans?plans?

Components of Mass Prophylaxis PlanComponents of Mass Prophylaxis Plan

Created by the Department of Public Health, Weill Medical College of Cornell University, NYCOEM, and NYCDOHMH

SAMPLE PATIENT FLOW DIAGRAM FOR MASS ANTIBIOTIC DISPENSING

Ambulance Bus

Drug Delivery

Entry

TriageArea

Medical Evaluation

DrugDispensing

Hospital

Exit

Airport

VERY SICK GET TRANSPORTTO MEDICAL FACILITY

HEALTHY PEOPLE GET PROPHYLAXISAMBULATORY SICK GET TREATMENT

SAMPLE PATIENT FLOW DIAGRAMFOR MASS ANTIBIOTIC DISPENSING

Created by the Department to Public Health, Weill Medical College of Cornell Univeristy, NYCOEM, and NYCDOHMH

Figure 1: Basic dispensing center design

Non-Infected Need Transport

Infected Need Transport

Non-Infected

Infected

TRIAGE

EVALUATION DISPENSING

ASSISTANCE WITH TRANSPORTATION TO HOSPITAL

SENT HOME

R

SENT TO HOSPITAL

SCHEMATIC FLOW THROUGH SIMPLE DISPENSING MODEL

Steady-state assumptionSteady-state assumption

Steady state develops if Steady state develops if == RR//STSTwherewhere RR==patient arrival patient arrival raterate

S = # staffS = # staff TT==mean service timemean service time

• When When ==then S = RT, orthen S = RT, orStaff required at

a station=

Rate of patient arrival at that

station

Mean station processing time

per patientX

SCHEMATIC SCHEMATIC FLOW THROUGH FLOW THROUGH WEILL/CORNELL WEILL/CORNELL SMALLPOX SMALLPOX VACCINATION VACCINATION MODELMODEL

CR

ISIS

CO

UN

SE

LIN

G

HOME

GREETING/ENTRYSCREENING

FORMDISTRIBUTION

TRIAGE

MEDICAL/CONTACT

EVALUATION

Transport to MedicalCare Facility

WITNESSEDCONSENT &

VACCINATIONFORM

COLLECTION& EXIT

COUNSELINGFORM

COLLECTION& EXIT

COUNSELING

BRIEFING,CONSENT

SUSPECTBRIEFING,CONSENT

Not Suspect Caseor Contact Post-Event

Component:Suspect Cases and

ContactsFORMDISTRIBUTION

FORMDISTRIBUTION

BRIEFING,CONSENT

WITNESSEDCONSENT &

VACCINATION

CRISISCOUNSELING

HOME

QUARANTINEFACILITY

FORMCOLLECTION &

EXITCOUNSELING

POST-EVENT CONTACT PRECAUTION AREA

C

A1

A2+A3[=0% IF PRE-

EVENT]

HOME

“Anyone not feeling well [or who thinks they may have come incontact with someone with smallpox], come this way, please”

B

B

C

B

A

A4

QUARANTINECOUNSELING

D

D

Place N95 mask on patient

DECLINEVACCINATION

CRITICAL

WITNESSEDCONSENT &

VACCINATION

TESTING

CONTRAINDICATIONor DECLINE

TESTING

CONTRAIND.OR DECLINE

R

Weill/Cornell Weill/Cornell Smallpox Smallpox Vaccination Vaccination Staffing Staffing ModelModel

CR

ISIS

CO

UN

SE

LIN

G

HOME

GREETING/ENTRYSCREENING

FORMDISTRIBUTION

TRIAGE

MEDICAL/CONTACT

EVALUATION

Transport to MedicalCare Facility

WITNESSEDCONSENT &

VACCINATIONFORM

COLLECTION& EXIT

COUNSELINGFORM

COLLECTION& EXIT

COUNSELING

BRIEFING,CONSENT

SUSPECTBRIEFING,CONSENT

Not Suspect Caseor Contact Post-Event

Component:Suspect Cases and

ContactsFORMDISTRIBUTION

FORMDISTRIBUTION

BRIEFING,CONSENT

WITNESSEDCONSENT &

VACCINATION

CRISISCOUNSELING

HOME

QUARANTINEFACILITY

FORMCOLLECTION &

EXITCOUNSELING

POST-EVENT CONTACT PRECAUTION AREA

C

A1

A2+A3[=0% IF PRE-

EVENT]

HOME

“Anyone not feeling well [or who thinks they may have come incontact with someone with smallpox], come this way, please”

B

B

C

B

A

A4

QUARANTINECOUNSELING

D

D

Place N95 mask on patient

DECLINEVACCINATION

CRITICAL

WITNESSEDCONSENT &

VACCINATION

TESTING

CONTRAINDICATIONor DECLINE

TESTING

CONTRAIND.OR DECLINE

R

PRE-EVENT

Weill/Cornell Weill/Cornell Smallpox Smallpox Vaccination Vaccination Staffing Staffing ModelModel

CR

ISIS

CO

UN

SE

LIN

G

HOME

GREETING/ENTRYSCREENING

FORMDISTRIBUTION

TRIAGE

MEDICAL/CONTACT

EVALUATION

Transport to MedicalCare Facility

WITNESSEDCONSENT &

VACCINATIONFORM

COLLECTION& EXIT

COUNSELINGFORM

COLLECTION& EXIT

COUNSELING

BRIEFING,CONSENT

SUSPECTBRIEFING,CONSENT

Not Suspect Caseor Contact Post-Event

Component:Suspect Cases and

ContactsFORMDISTRIBUTION

FORMDISTRIBUTION

BRIEFING,CONSENT

WITNESSEDCONSENT &

VACCINATION

CRISISCOUNSELING

HOME

QUARANTINEFACILITY

FORMCOLLECTION &

EXITCOUNSELING

POST-EVENT CONTACT PRECAUTION AREA

C

A1

A2+A3[=0% IF PRE-

EVENT]

HOME

“Anyone not feeling well [or who thinks they may have come incontact with someone with smallpox], come this way, please”

B

B

C

B

A

A4

QUARANTINECOUNSELING

D

D

Place N95 mask on patient

DECLINEVACCINATION

CRITICAL

WITNESSEDCONSENT &

VACCINATION

TESTING

CONTRAINDICATIONor DECLINE

TESTING

CONTRAIND.OR DECLINE

R

POST-EVENT

SAMPLE SAMPLE OUTPUT OF OUTPUT OF WEILL/CORNELL WEILL/CORNELL SMALLPOX SMALLPOX VACCINATION VACCINATION MODELMODEL

SAMPLE SAMPLE OUTPUT OF OUTPUT OF WEILL/CORNELL WEILL/CORNELL SMALLPOX SMALLPOX VACCINATION VACCINATION MODELMODEL

Predicted Length of Vaccination Campaign as a Function of Available Core Staff and Population Size

0

5

10

15

20

25

30

35

40

45

50

Available Core Staff

Day

s to

Vac

cin

ate

Pop=100K

Pop=500K

Pop=1MM

Pop=2.5MM

Pop=5MM

Pop=8MM

4 Days

13

57

911

1315

1719

2123

2527

29

12131415161718192021222324

0

5000

10000

15000

20000

25000

30000

35000

40000

45000

Nu

mb

er

of

Pati

en

ts p

er

Day

Flow Rate (pt/min/POD)

Hours of Operation

Trend in Number of Patients Served by POD per Day of Vaccination Campaign as a Function of POD Flow Rate (pt/min/POD) and POD Hours of Operation*

*Assumes a campaign targetting 8MM people over 4 days

LimitationsLimitationsAccuracy of any model depends on the quality of Accuracy of any model depends on the quality of the underlying data the underlying data Processing times are critical variableProcessing times are critical variable

Output is design-specificOutput is design-specific A differently designed vaccination center may give a A differently designed vaccination center may give a

different resultdifferent result

Multiple scalable centers with externally Multiple scalable centers with externally controlled patient flowcontrolled patient flow Feasible but requires law enforcement inputFeasible but requires law enforcement input

These numbers reflect only critical dispensing These numbers reflect only critical dispensing staff and do not include support staff for the staff and do not include support staff for the centers or distribution and logistics staffcenters or distribution and logistics staff

ConclusionsConclusionsSpreadsheet modeling allows planners to “think Spreadsheet modeling allows planners to “think with numbers” when designing mass prophylaxis with numbers” when designing mass prophylaxis response strategiesresponse strategiesModeling forces critical examination of:Modeling forces critical examination of: Assumptions about vaccination center layout and Assumptions about vaccination center layout and

processesprocesses Availability of resourcesAvailability of resources

Model estimates are useful data to guide Model estimates are useful data to guide planning but do not replace the real thing: planning but do not replace the real thing: LIVE, REALISTIC EXERCISESLIVE, REALISTIC EXERCISES

AcknowledgmentsAcknowledgmentsCo-Investigators Co-Investigators Jason Cuomo, MPHJason Cuomo, MPH Mark A. Callahan, MDMark A. Callahan, MD Alvin I. Mushlin, MD, ScMAlvin I. Mushlin, MD, ScM

NYC Office of Emergency ManagementNYC Office of Emergency ManagementEdward Gabriel, MPA, AEMT-PEdward Gabriel, MPA, AEMT-PSam Benson, AEMT-PSam Benson, AEMT-PAnita Sher, MIAAnita Sher, MIA

U.S. DHHS, Office of the Asst. Sec’y for Public Health U.S. DHHS, Office of the Asst. Sec’y for Public Health PreparednessPreparednessCapt. Ann Knebel, RN, DNScCapt. Ann Knebel, RN, DNSc

NYC Dept. of Health, Communicable Disease UnitNYC Dept. of Health, Communicable Disease UnitMarci Layton, MDMarci Layton, MDSue Blank, MD, MPHSue Blank, MD, MPH

NY Presbyterian Healthcare SystemNY Presbyterian Healthcare SystemEliot Lazar, MDEliot Lazar, MDArthur Klein, MDArthur Klein, MDNeal Flomenbaum, MDNeal Flomenbaum, MD