Emergency Preparedness / Stockpiling

1. Emergency Preparedness / Stockpiling

2. Emergency Preparedness Case • You are part of the team that is called to respond to a natural outbreak or possible terrorist attack involving an infectious agent. • Multiple attendees of an outdoor concert festival have presented in the 1-3 days following with “flu-like” symptoms, black rashes on finger and toes and painful swellings in their groin and armpits

3. Rashes A tentative diagnosis of plague is made

4. Responsibilities • Your team is assigned to mass dispensing of prophylactic antibiotics to other attendees of the concert which took place over 3 days and had an estimated 350,000 visitors and staff • What team is this anyway? • So what are you dispensing and where does it come from? • A Stockpile, right?

5. Question 1) Answer: Medical Outreach Team • Alerted and formed from locally organized disaster plans, ie HEICS. • Composed of physicians, nurses, EMT, preventive medicine staff and pharmacists • Drug info / dispensing / distribution • Patient education • Non-traditional clinical functions during an emergency • Triage and physical assessment • Taking histories to exclude contraindications • Medication administration • Collection of epidemiological data; screening surveys

6. Question 2) Answer:“Pills to the People” • The Problem with Stockpiling • Antidotes and treatments are expensive • Have limited shelf-lives • Unlikely to be used in large quantities • 350,000 for prophylaxis • 2 doses daily for > 7 days of Cipro or Doxycycline • 4.9 million doses • Clearly exceeds local supply • What plans currently exist for such a disaster?

7. Terrorism or Large Scale Natural Disaster • Require rapid access to large quantities of pharmaceuticals and medical supplies TIMELINE • CDC formed an antidote/antibiotic depot for 1996 Summer Olympics in Atlanta • Congressional charge to Health and Human Services and to Centers for Disease Control and Prevention in 1999 created National Pharmaceutical Stockpile (NPS) • Re-supply of large quantities of essential medical materiel to states and communities during an emergency within 12 hours of the federal decision to deploy. • Plans subsequently updated in 2002

8. Strategic National Stockpile (Homeland Security Act of 2002) • Tasked DHS with defining the goals and performance requirements and managing the deployment of assets. • Effective on 1 March 2003, the NPS became the strategic national stockpile (SNS) managed jointly by DHS and HHS. • The SNS program works with governmental and non-governmental partners to upgrade the nation’s public health capacity to respond to a national emergency. • Critical is ensuring capacity to receive, stage, and dispense SNS assets • Federal, state, and local levels

9. Strategic National Stockpile • Repository of • Antibiotics • Vaccines • Immunoglobulins • Chemical antidotes • Antitoxins • Life-support medications • IV administration • Airway maintenance supplies • Medical/surgical items

10. SNS: Push Packages • Strategically located throughout US • Supplement and re-supply state and local public health agencies in the event of a national emergency • When: Anywhere and Anytime • Where: Within the U.S. or its territories

11. Containers designed to facilitate shipping by highways and railways. And also by airways.

12. SNS ProgramDelivery and Transport • Push packages can be delivered within 12 hours of a federal decision to deploy. • Authority for material will transfer upon arrival • Once package is on the tarmac, responsibility shifts from federal to local authorities • SNS technical advisory response unit (TARU) staff will arrive and remain • Coordinate with state and local officials for efficient delivery and distribution

13. Push Package “Deployment” • Local emergency management and public health authorities determine that the demand for pharmaceuticals will exceed local supply. • They will notify their respective central offices • Decision is made to discuss with governor. • If appropriate, the governor will request the push package from CDC or DHS. • DHS, HHS, CDC, and other federal officials will evaluate the situation and determine a prompt course of action. • Short turn around time expected.

14. SNS: Follow up(Not necessarily second line response) • Vendor managed inventory (VMI) supplies • Arranged contractually with majormanufacturers • ie, Bayer had agreed to supply 300 million Cipro to U.S. government (100 now 200 on re-supply) • Shipped to arrive within 24 to 36 hours. • Can be tailored to the suspected or confirmed agent(s). • Could act as the first option for immediate response from the SNS if agent is known.

15. Supplementing State and Local Resources • The SNS is not a first response tool • Significant exposure to nerve agents will require an antidote within minutes • What would we do then?Chempack • During a national emergency, state, local, and private stocks of medical material will be depleted quickly • State and local first responders and health officials can use the SNS to bolster their response with a 12-hour push package, VMI, or both

16. Instructions for deploying the SNS Push Package

17. NYC Drill Mass Dispensing function - deployment

20. 350,000 “patients” • Local supply now • 3400 Cipro • 1 b.i.d. x 7 days • Can only treat 200?

21. Antibiotics to Counteract Biologic Weapons • Often older agents are still the most effective. • Dosage regimens vary depending on • Bacterial agent being treated • Treatment vs. prophylaxis • Most expensive drug is not necessarily the better drug!

22. Must be in a position to: • Advise public health officials on appropriate messages to convey to the public about the use of essential pharmaceuticals after an attack Effectiveness of alternatives

23. Post-exposure Prophylaxis

24. Treatment

25. Dispensers must be in a position to: • Advise public health officials on appropriate messages to convey to the public about the use of essential pharmaceuticals after an attack • Adverse effects • Contraindications • Effectiveness of alternatives • Potential for development of drug resistance

26. What about contraindications? • Isn’t ciprofloxacin bad for kids? • Isn’t same true for doxycycline? • What if patient is pregnant? Or breastfeeding • Drug Interactions?

27. When alternatives are available, these agents should be avoided in pregnant women or young children. However, acts of bioterrorism shift the benefitsuch that these agents should NOT be excluded as viable treatments in these populations if the accepted alternatives are not available.

28. Contraindications • ALL contraindications need to be reassessed in the event of a bioterrorism event.

29. Special Populations IssuesPediatrics • Quinolones are indicated for treatment of anthrax and for post exposure prophylaxis in children < 18 y/o • Doxycycline is indicated for treatment of anthrax and for post exposure prophylaxis in children < 8 y/o • Use with sensitivity indications, allergy, exhaustion of supplies of cipro or penicillin, • Doxycycline (tetracyclines)

30. Special Populations IssuesPregnancy • Concerns of teratogeneticity with quinolones (arthroparthies) must be weighed against risk of severe life-threatening infections such as represented by Class A agents • Concerns of teratogeneticity with tetracyclines must be weighed against risk of severe life-threatening infections such as represented by Class A agents • Tetracyclines may cause teeth discoloration when given for prolonged periods during late pregnancy (such as anthrax prophylaxis)

31. Special Populations IssuesGeriatrics • Quinolones are potent inhibitors of CYP 3A4 and 1A2 and doses need adjust for renal insufficiency • Doxycycline undergoes CYP 3A4 interactions as a substrate and inhibitor • Review your lists and counsel patient on questions to ask their primary care provider

32. What if this were toxins or chemicals? • Decontamination • Supportive care • Anti-toxin when available • Botulism: depending on serotype • Investigational vaccines: • Botulism

33. Antidote • Atropine • Blocks the effects of neurotransmitter • Dosing is symptomatic and often exceeds “normal” • Eye drops effective for ocular symptoms (also provide easy source for a lot of drug – but homatropine not as potent) 2-PAMCl (Pralidoxime) - Removes nerve agent from the enzyme • Military Autoinjector • MARK I

36. “Aging”

37. Treatment • Adult atropine dose: “enough” • Give atropine regardless of heart rate • Pediatric Considerations • 0.01mg/kg • Atropine used until endpoint achieved (resolution of secretions) • In Iran doses between 100-1000 mg/daily were used

38. Cyanide Treatment • Remove from source • Oxygen • Cyanide antidote kit

39. NO ONEable to walk and talk is in immediate danger of loss of life

40. Toxins • Decontamination • Supportive care • Anti-toxin when available • Botulism: depending on serotype • Investigational vaccines: • Botulism

41. Treatment of Botulism Mainstays of Therapy • supportive care • passive immunization with equine antitoxin • Botulinum antitoxin is available from the CDC via state and local health departments • The licensed trivalent antitoxin contains neutralizing antibodies against botulinum toxin types A, B, and E. • If other toxin types are disseminated, patients could potentially be treated with an investigational heptavalent (ABCDEFG) antitoxin held by the US Army Updates

42. Agents for Radiation Exposure • Potassium Iodide • Ca-DTPA, Zn-DTPA • Prussian Blue • Supportive Care

43. Radioiodines and Thyroid Cancer Radioiodines concentrate In the thyroid gland and can increase the risk of thyroid cancer

44. You can reduce the radioiodine thyroid dose by giving potassium iodide • Potassium Iodide (KI) considerations • Who should get KI? • Useful at the beginning of an exposure • Only protects against thyroid cancer

45. Dosage (KI)

47. Specific Therapy

48. So now that we know what to do, we will be alright, right?

50. Chempacks • Will be placed in preselected areas within the state and contain: • MARK-1 autoinjectors • 2mg atropine & 600mg 2-PAM • Bulk atropine sulfate • Bulk 2-PAM • Pediatric atropine auto injectors • 0 .5mg and 1.0mg • Diazepam (CANA kits) • Bulk diazepam • IV fluids and catheters