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“Racing to Beat the Clock”Texas-Sized Issues Associated with the
Transportation of Select Agents from Rural Hospitals to Reference
LaboratoriesAlberta Wang
Mentor: Grace Kubin, Ph.D.
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INTRODUCTION
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Background
Emerging infectious diseases
Biological terrorismHistory of biological warfareTerrorist attacks of September 11, 2001Anthrax spores released October 12, 2001
Chemical terrorismHistory of chemical warfareCharacteristics of chemical weapons
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Laboratory Response Network
Established in 1999 by the CDCFounding partners: FBI, APHL, CDCTwo laboratory network divisions
Biological terrorismChemical terrorism
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Network for Biological Terrorism
Sentinel laboratories
Reference laboratories
National laboratories
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Network for Chemical Terrorism
Level 3
Level 2
Level 1
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Emergency Preparedness
Local Health Departments (LHDs)State Health Departments:1. Build relationships with the clinical community2. Enable rapid communication3. Increase lab connectivity and training4. Conduct proficiency testing
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Shipping & Handling Agents
Shipping & Handling:1. Collection process2. Initial processing before storage or analysis3. Transport
Affects sample quality and test results
Maintains viability of living organisms
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CDC Performance Measure Standards
In an emergency, target times for shipping:sentinel labs
Infectious biological agent = 60 minutes
Hazardous chemical agent = 180 minutes
Environmental samples = 60 minutes
reference labs
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Transportation Regulations
International:International Air Transport Association (IATA)UN Committee of Experts (UNCOE)
Domestic:U.S. Department of Transportation (DOT)Code of Federal Regulations (CFR)Federal Aviation Authority (FAA)
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Texas Sized Problem
Large rural areas in the south and west
Rural populations:Underestimate possibility of terrorist attackLack dependable transportationNeed laboratory personnel training
Metropolitan areas delivery times <2 hours
Rural areas delivery times 5+ hours
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Texas LRN
DSHS
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Purpose
Measure Texas LHDs’ emergency shipping and handling readiness
Identify commercial courier services that can meet the needs of the Texas LRN
Develop a specimen shipping plan for the Texas LRN laboratories to submit suspect agents to DSHS following CDC performance measure standards.
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METHODS
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Methods
Identify rural areas needing couriers
Measure emergency handling readiness of Texas LHDs
Identify couriers able to meet needs of Texas LRN
Develop specimen shipping plan
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Identify Rural AreasNeeding Couriers
Surveyed 80 rural hospital laboratoriesPublic Health Intern - Taylor Johnson42 cannot meet CDC performance measures
Factors limiting performance:Lack of handling training – 27%Lack of courier service or distance – 73%
Identified rural Texas areas needing couriers
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Austin20%
Houston10%
San Antonio10%
Tarrant5%
Tyler21%
Wichita Falls2%
El Paso5%
Dallas2%
Corpus Christi5%
Lubbock20%
AustinCorpus ChristiDallasEl PasoHoustonLubbockSan AntonioTarrantTylerWichita Falls
Distribution of Rural Texas Laboratories Unable to Meet CDC Performance
Measure Standards by LRN Region
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Methods
Identify rural areas needing couriers
Measure emergency handling readiness of Texas LHDs
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Methodology
Create survey for Texas LHDsTarget laboratory or bioterrorism directorsDraft questions
Administer surveyCall all 65 Texas LHDsFollow up on calls
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Texas LHD Survey Questions
Mode(s) of transportation currently used to ship suspect agents to reference labs?
Emergency shipping and handling protocol?
If so, what mode(s) of emergency shipping and handling were planned?
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Methods
Identify rural areas needing couriers
Measure emergency handling readiness of Texas LHDs
Identify couriers able to meet needs of Texas LRN
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Identify Qualified Couriers
1. Three criteriaService area includes TexasTransport medical and hazardous materialsHazmat certified
2. Research couriersPreliminary researchFinal comparison test
3. Select 2 best couriers
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Preliminary Courier Research
Identify 34 potential couriersCreate survey questions
Hazmat certified?Service area?Availability? 24/7? Holidays?Methods of transportation?Tracking?
Call all 34 couriers Reduce to 14 potential couriers
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Choosing the Final Couriers
Compare courier efficiencies:Pickup timesTransport timesCost
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Port Arthur
Nacogdoches
El Paso
Horizon City
Austin
San AntonioDel Rio
Laredo
Harlingen
Houston
Paris
Gilmer
Tyler
Lubbock
Fort Worth
Dimmitt
Seminole
Colorado City
Bowie
Eastland
Hamilton
La Grange
Fairfield
Columbus
Courier Test Locations
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Data Collection and Analysis
Excel
Access
ArcView
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Methods
Identify rural areas needing couriers
Measure emergency handling readiness of Texas LHDs
Identify couriers able to meet needs of Texas LRN
Develop specimen shipping plan
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Develop SpecimenShipping Plan
Incorporate results from:Rural hospital laboratory surveyTexas LHDs surveyCourier research
RecommendationsCDC Performance MeasuresPlan of action
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RESULTS
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Results
Emergency handling readiness of Texas LHDs
Couriers able to meet needs of Texas LRN
Specimen shipping plan
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LHD Survey Response Rate
72%
28%
Received Response No Response
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02468
101214161820
Non
e
Loca
l Law
Enfo
rcem
ent
LHD
Pers
onne
l
Com
mer
cial
Cou
rier
Hos
pita
l Lab
sTr
ansp
ort
Inde
pend
ently
Dep
artm
ent o
fPu
blic
Saf
ety
Sate
llite
Lab
s'C
ourie
rs
Modes of Transportation
Num
ber o
f LH
Ds
Methods of Transportation Used by Texas LHDs to Ship Suspect Agents to
Reference Laboratories(40.4%)
(17.0%) (17.0%)
(8.5%)(4.3%)
(2.1%) (2.1%)
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Emergency Handling Protocol Readiness of Texas LHDs
No Protocol40%
Protocol Developed
19%
Do Not Know28%
In Development
13%
No ProtocolIn DevelopmentProtocol DevelopedDo Not Know
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0
1
2
3
4
5
6
EMS Helicopter Local LawEnforcement
Mail to DSHS Protocol NotSpecified
Modes of Emergency Shipping & Handling
Num
ber o
f LH
Ds
Methods of Emergency Shipping & Handling Planned by Texas LHDs
(11.1%) (11.1%) (11.1%) (11.1%)
(55.6%)
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Results
Emergency handling readiness of Texas LHDs
Couriers able to meet needs of Texas LRN
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Preliminary Courier Results1. FedEx Custom Critical2. Jet Express Couriers, Inc.3. TexEx Courier & Messenger4. Green Light Delivery, Inc.5. DHL Express6. Air Courier Dispatch7. City Sprint8. Medicare Express Delivery Service, Inc.9. Corporate Couriers10. AHS Courier11. ASP (Landstar Network)12. Panther II Transportation13. Rapid Delivery Service, Inc.14. UPS Hazardous Materials Support Center
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Delivery Time and Cost
($757.99)8 hours 53 mins($790.00)7 hours 30 minsSouth Texas
($1,316.75)14 hours 54 mins($1,406.93)10 hoursEl Paso
($687.00)8 hours 25 mins($550.00)7 hoursTyler
($1,060.04)19 hours 24 mins($1,104.00)8 hoursLubbock
($300.22)5 hours 13 mins($270.00)3 hours 40 minsAustin
FedEx Custom CriticalAir Courier DispatchLRN Region
Delivery Time to DSHS (Cost)
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Delivery Time Map
El Paso
Port Arthur
NacogdochesHorizon City
Austin
San Antonio
Del Rio
Laredo
Harlingen
Houston
Paris
Gilmer
Tyler
Lubbock
Fort Worth
Dimmitt
Seminole
Colorado City
Bowie
Eastland
575 mi10 hours
331
mi
7 hr
s 30
min
s
8 hrs169 mi
156
mi
6 hr
s
282 m
i –7 h
rs
390 mi8 hrs
189
mi
4 hr
s 30
min
99 mi – 6 hrs
82 mi
4 hrs 40 min 102 m
i4 hrs
4 hrs95 mi
69 mi
3 hrs
3 hrs
15 m
in
81 m
i
77 mi
4 hrs 30 min
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Courier Recommendation
1. Air Courier DispatchBest overall cost and delivery timesWorldwide full-service courierAll drivers receive biohazard training
2. FedEx Custom CriticalSecond in cost and delivery timesStrong international reputationSpecialize in critical-care transport
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Results
Emergency handling readiness of Texas LHDs
Couriers able to meet needs of Texas LRN
Specimen shipping plan
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Specimen Shipping Plan
1. Establish accounts with:Air Courier DispatchFedEx Custom Critical
2. Develop guidelines for account usage3. Update Collection, Packaging, & Shipment
Protocol Plan and report to CDC4. Distribute plan to Texas LRN laboratories
Rural hospital laboratoriesLocal Health Departments
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Conclusions
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Conclusions
Meeting CDC Performance Measures
is still Texas-sized problem!
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Acknowledgements
Dr. Grace KubinMarianne GarciaTDSHSNancy ElderDr. Field
Thank you for your guidance, resources, time, and support!
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Acknowledgements
The Public Health Internship Program is sponsored by The University of Texas at Austin School of
Biological Sciences, The Texas Department of State Health Services, and The Austin/Travis County
Health and Human Services Department.
Funding generously provided by The Centers for Disease Control and Prevention,
Epidemiology and Laboratory Capacity for Infectious Diseases Program