emergency preparedness / stockpiling. emergency preparedness case you are part of the team that is...

Emergency Preparedness / Stockpiling



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


Rashes

A tentative diagnosis of plague is made


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

1. What team is this anyway?2. So what are you dispensing and where

does it come from? • A Stockpile, right?


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


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?


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


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


Strategic National Stockpile• Repository of

– Antibiotics– Vaccines– Immunoglobulins– Chemical antidotes– Antitoxins– Life-support medications– IV administration– Airway maintenance

supplies– Medical/surgical items


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


Containers designed to facilitate shipping by highways and railways.

And also by airways.


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


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.


SNS: Follow up(Not necessarily second line response)

• Vendor managed inventory (VMI) supplies• Arranged contractually with major manufacturers

– 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.


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

Instructions for deploying the SNS Push Package


NYC Drill Mass Dispensing function - deployment


•350,000 “patients”

•Local supply now

• 3400 Cipro

• 1 b.i.d. x 7 days

• Can only treat 200?


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!


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


Post-exposure Prophylaxis

Bacteria 1st choice Alternatives

AnthraxCiprofloxacin

Doxycycline

rifampin, penicillin, ampicillin, chloramphenicol, clindamycin, and clarithromycin.

PlagueDoxycycline

CiprofloxacinChloramphenical

TularemiaDoxycycline

Ciprofloxacin


TreatmentBacteria 1st choice Alternatives

AnthraxCiprofloxacin

Doxycycline

rifampin, vancomycin, penicillin, ampicillin, chloramphenicol, imipenem, clindamycin, and clarithromycin.

PlagueGentamicin

Streptomycin

Doxycycline, Ciprofloxacin

Chloramphenical

TularemiaGentamicin

Streptomycin

Doxycycline, Ciprofloxacin, Chloramphenicol


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


What about contraindications?

1. Isn’t ciprofloxacin bad for kids?

2. Isn’t same true for doxycycline?

3. What if patient is pregnant? Or breastfeeding

4. Drug Interactions?


When alternatives are available, these agents should be avoided in pregnant women or young children.

However, acts of bioterrorism shift the benefit

such that these agents should NOT be excluded as viable treatments

in these populations if the accepted alternatives are not available.


Contraindications

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


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)


• 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)

Special Populations IssuesPregnancy


• 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

Special Populations IssuesGeriatrics


What if this were toxins or chemicals?

• Decontamination

• Supportive care

• Anti-toxin when available

– Botulism: depending on serotype

• Investigational vaccines:

– Botulism


• 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

Antidote


Name Synonym Aging T1/2

Sarin GB ~5 hours

Soman GD ~2 min

Tabun GA >40 hours

VX None >40 hours

“Aging”


• 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

Treatment


Cyanide Treatment

• Remove from source

• Oxygen

• Cyanide antidote kit


NO ONEable to

walk and talk is in immediate danger of loss

of life


Toxins

• Decontamination• Supportive care• Anti-toxin when available

– Botulism: depending on serotype

• Investigational vaccines:– Botulism


Treatment of BotulismMainstays 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


Agents for Radiation Exposure

• Potassium Iodide

• Ca-DTPA, Zn-DTPA

• Prussian Blue

• Supportive Care


Radioiodines and Thyroid Cancer

Radioiodines concentrateIn the thyroid gland and can increase the risk ofthyroid cancer


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


Dosage (KI)

Age Group Dosage

Infants < 1 month 16 mg

Children 1 month – 3 yrs

32 mg

Children 3–18 yrs 65 mg

Adults 130 mg


Specific TherapyRadionuclide Therapeutic Approach

Tritium Dilution (force fluids)

Iodine-125 or I-131 KI, or SSKI

Cesium-134 or cesium- 137

Prussian blue

Strontium-89, or 90 Decrease abs (antacids), blockage (strontium lactate), displacement (oral phosphate), mobilization (ammonium chloride)

Plutonium Zn or Ca (-DTPA)


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


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


Chempack


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emergency preparedness / stockpiling. emergency preparedness case you are part of the team that is...

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