Privately owned vehicles were filled with cookie orders, simulating the pickup of medical countermeasures by closed POD partners that could potentially arrive at the LBSS with any variety of public and privately owned vehicle (Source: Baltimore County Department of Health and Human Services, 2015).

Best Practices – From Cookies to Countermeasures

The anthrax attacks in October 2001 were a wakeup call nationwide of America’s weakness to respond to a widespread biological terrorist incident. Since that time, local, state, and federal agencies have worked together to improve public health readiness to mass dispense medical countermeasures (MCM) at points-of-dispensing (PODs). Providing bulk dispensing to non-public (or “closed”) PODs is one methodology employed to expedite the distribution of MCM to the private sector. However, exercising bulk dispensing in a realistic environment can present numerous challenges. Finding non-traditional partners, such as the Girl Scouts of Central Maryland, provides a cost-effective and simple solution to reducing the artificialities of a functional exercise.

Despite current age of sophisticated technology, the mass dispensing of medical countermeasures – namely oral antibiotics for widespread post-exposure to aerosolized Anthrax – remains a fairly uncomplicated and rudimentary concept: get the pills into as many people as possible, as quickly as possible. For almost two decades since 2001, local health departments have repeatedly practiced mass dispensing drills using seasonal vaccinations and other forms of MCM simulations to test the throughput of their public PODs.

Closed PODs serve specific areas and designated populations such as the private sector, critical infrastructure, first responders, healthcare facilities, and campuses and/or structures where large clusters of people reside. Closed PODs are designed so that these pre-identified locations distribute countermeasures to their own respective populations. This process reduces the overall numbers of populace who would otherwise have to report to a public POD to receive medications for themselves and their households and, therefore, reduces the number of hours necessary to reach an entire county or region.

Although it is the responsibility of the state to ensure secure and safe delivery of federal assets such as MCM to local level PODs, a bulk POD – referred to in Maryland as a local bulk shipment site (LBSS) – must be established so that closed PODs can rapidly pick up their allotment of medications. They then return to their campuses and structures to dispense to their specific populations while the simultaneous public POD operation gets underway with the general public. With potentially thousands of closed PODs identified as well as the planning obstacle of traffic congestion during a public health emergency, the LBSS allows for just one drop shipment for smaller sized closed PODs per county.

How the Local Bulk Shipment Site (LBSS) Functions

Baltimore County, Maryland, is geographically the largest and third most populated county in the state, with hundreds of potential closed POD sites, including over 300 nursing homes and assisted living facilities. Instead of pushing small to medium size shipments of MCM to these facilities, which would logistically tax the limited trucking resources available, facilities would be notified via an automated call-down and text alert system of the LBSS location. Facilities and pre-identified organizations would then send an appropriate sized vehicle and staff to the LBSS, sign for the medical materiel, and quickly return to their facilities to begin immediate internal dispensing.

Exercising the LBSS

In concept, the LBSS is remarkably simple: Drive up. Sign for MCM. Return to facility to dispense. Re-supply as necessary.

Exercising the LBSS to accurately measure up to federal benchmarks proves to be slightly more difficult due to the artificialities created by the exercise environment. To realistically exercise the LBSS, a local jurisdiction would need the following:

  • Thousands of cases of simulated medical countermeasures;
  • Numerous vehicles of different sizes and capacities; and
  • Hundreds of volunteers or players representing closed PODs.

Those receiving federal grant dollars to prepare for biological attacks are required to demonstrate competency and efficiency in all aspects of dispensing and distribution. Although seasonal flu clinics provide an environment to use a live scenario and actual patients to test POD layouts and throughput, there are few opportunities to exercise a bulk POD and/or a closed POD. To effectively test bulk and closed PODs, exercise coordinators would require significant amounts of exercise participants, vehicles, and supplies as well as an enormous block of time. For a county such as Baltimore County, the LBSS exercise required hundreds of people and vehicles to portray the closed POD representatives and thousands of boxes of simulated countermeasures. To truly determine full operational capability, the exercise should be conducted over the course of several days to several weeks, as an anthrax response could require POD operations for up to two months.

Obtaining this volume of supplies and staff – even volunteers – could result in significant costs to departments already strained by small staff and shrinking budgets. Using only a few staff with vehicles and supplies repeatedly to simulate crowds is an exercise artificiality that may result in flawed throughput numbers and a false confidence in the true operational capability of an LBSS or bulk/closed POD.

The Centers for Disease Control and Prevention (CDC) performs an annual Operational Readiness Review (ORR) that requires testing the local ability to perform materiel management and distribution. This capability includes a demonstrated ability to perform receipt, staging, and storing of materiel as well as other key functions such as order picking, inventory management, and chain-of-custody maintenance. However, this review places a strain on both public health and emergency management programs, which must find ways to exercise in a cost-effective fashion without an overabundance artificiality.

The Solution: A Perfect Partnership With the Girl Scouts of Central Maryland

Sometimes the best solutions are the simplest ones: in this case, the Girl Scouts of Central Maryland annual cookie drive. Baltimore County Department of Health and Human Services partnered with Girl Scouts of Central Maryland to perform a fully functional, 45-day exercise that fully tested every operational component of the county’s LBSS/bulk POD plan. The Girl Scout’s annual cookie drive requires distribution of more than 7,000 cases across the region over the course of just under two months. Remarkably similar to the bulk dispensing to closed POD partners, Girl Scouts of Central Maryland utilize central warehouses as “depots” for the initial receipt and distribution of orders. To ensure fairness (cookie sales are highly competitive between troops), all troops receive their initial troop orders on the same day and then return to their troops to distribute the individual boxes to the scouts for cookie sales. After this initial push, “cupboards” are established, and all resupply and additional orders of cookies by the case are arranged and picked up at these locations.

Sapps-Photo 1

In comparison, a bulk POD or LBSS would require all closed POD partners such as nursing homes, colleges, hotels, etc. to pick up medical countermeasures, by the case, within an extremely short window of time and return to their respective facilities and communities to dispense the countermeasures. If additional amounts are needed or if the impacted population must continue taking antibiotics for a full 60-day treatment (such as the case with aerosolized anthrax), then the bulk POD/LBSS will handle the resupply effort as well for up to 50 days.

Sapps-Photo 2

Truckloads of simulated medical countermeasures (MCM) in the form of Girl Scout Cookies arrive weekly to be placed into inventory and split into orders (Source: Baltimore County Department of Health and Human Services, 2015).

For this exercise, a memorandum of understanding was signed between Girl Scouts of Central Maryland and Baltimore County Department of Health and Human Services. More than 2,000 cases were received by truck delivery at the LBSS, where they were placed into electronic inventory, split into orders, and prepared for bulk distribution. Girl Scout Troop leaders displayed their “cookie passport” to be allowed entry into the queue. They then queued in a drive-thru at the LBSS, where they signed chain-of-custody documents and had their vehicle loaded with cases. A quality assurance check was performed and inventory was maintained electronically. Deliveries of several thousand cases followed each week for the resupply efforts, which occurred during regular business hours each week. Overall, more than 7,100 cases of simulated medical countermeasures were distributed to over 500 volunteers over the course of a 45-day period. This was accomplished while maintaining all other critical departmental functions and without additional staff, allowing for a real-time test of the division’s continuity of operations plans (COOP).

Real Results at Almost No-Cost

This public-private partnership was a “win-win” for both parties. The Girl Scouts of Central Maryland were able to utilize free warehouse space for the purposes of cookie distribution and resupply. Based on feedback from the troops, the methodology utilized at the LBSS was well received due its speed, efficiency, and accuracy. Almost a third of the Central Maryland region’s cookies were handled by the LBSS. Based on time studies and staff after-action meetings, the LBSS could have handled four times that volume if necessary. For the Baltimore County Department of Health and Human Services, this provided an opportunity to exercise every aspect of the LBSS/bulk POD operation without the need for significant artificialities. This resulted in real-time data for throughput numbers and other logistical lessons learned. The sometimes hectic and competitive nature of cookie sales added the element of emotional stress to volunteers, providing staff a taste of realism that will be amplified during a public health emergency.

Sapps-Photo 3

Girl Scout Troops (simulating closed POD partners) queue up using a drive-thru method to receive orders of Girl Scout Cookies. They were stopped at a checkpoint to verify their “cookie credentials” to proceed (Source: Baltimore County Department of Health and Human Services, 2015).

Even more beneficial were the costs involved. Because the exercise was predominantly limited to daytime, normal business hours and Public Health Emergency Preparedness and Operations Bureau staff were utilized, there were minimal additional costs involved to perform the exercise other than some limited overtime for the depot day. All exercise supplies, materials, volunteer cookie recipients and vehicles were provided by the Girl Scouts. There was no cost to the Girl Scouts of Central Maryland to utilize the space or service.

Sapps-Photo 4

Quality assurance checks were performed prior to order fulfillment and a chain-of-custody document was signed at every step to ensure proper accountability for the cookies (Source: Baltimore County Department of Health and Human Services, 2015).

Countermeasure-to-Cookie Comparison

Remarkably, a case of Girl Scout Cookies was virtually identical to a standard case of antibiotics in both dimension and weight (see Table 1). Additionally, virtually every component of LBSS operation had a Girl Scout equivalent, including a chain-of-custody form and the duration of cookie operations.

Sapp Table 1

So here’s how it works: 1 case = 100 bottles of antibiotic tables (each bottle is a 10-day course for 1 person); 7,602 cases distributed x 100 bottles = 760,200 courses of medication. The U.S. Census for Baltimore County population estimate for 2017 is 832,468 and number of households estimate for 2017 is 336,824 (Source: Baltimore County Department of Health and Human Services, 2015).


The public-private partnership between Baltimore County Department of Health and Human Services and Girl Scouts of Central Maryland provided a strikingly realistic training environment to simulate the bulk distribution of MCM to closed POD partners. More than 760,200 simulated courses of medication were distributed from the LBSS, which represents at least two course of medication for every household in Baltimore County. It afforded an opportunity to exercise every aspect of the LBSS over a 45-day period, while sustaining normal daily operations in accordance with the continuity of operations plans and having minimal impact on daily operations. After the first exercise in 2015, subsequent exercises increased the volume of cookies distributed and expanded to become a regional exercise in 2017 and 2018. The most significant aspect was the minimal funding and staff involved for an exercise of this scope and magnitude. As public health emergency preparedness funding continues to decrease across the country, health departments and emergency management must find creative and innovative partnerships to test operational capability in a live environment.

Terry Sapp

Terry Sapp, EMT, CHEP, is the emergency operations coordinator for Baltimore County Health and Human Services where he serves as the program director of the Public Health Emergency Preparedness (PHEP) Division. He was formerly the State of Maryland Cities Readiness Initiative (CRI) coordinator and previously served as the New Mexico bioterrorism training coordinator. He has presented on mass dispensing tactics and public health readiness at numerous national conferences across the United States, including multiple presentations at the National Preparedness Summit, the Maryland Association of County Officials Conference, and the Maryland Emergency Management Association Symposium. He has served as a guest instructor for the Centers for Disease Control and Prevention (CDC) Strategic National Stockpile (SNS) course and a recent presenter for the CDC’s national “Wednesday Webinar.” He has 15 years of public health emergency management experience at the state and local levels and over 23 years of combined experience as a volunteer with organizations including the national Disaster Medical Assistance Team (DMAT), National Medical Response Team (NMRT), American Red Cross, Radio Auxiliary Communications Emergency Service (RACES), and the Pikesville Volunteer Fire Company. In his spare time, he is a tour/production assistant and a “roadie” in the rock music industry.



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