Emergency Preparedness /
Stockpiling
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
Emergency Preparedness / Stockpiling
Rashes
A tentative diagnosis of plague is made
Emergency Preparedness / Stockpiling
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?
Emergency Preparedness / Stockpiling
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
Emergency Preparedness / Stockpiling
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?
Emergency Preparedness / Stockpiling
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
Emergency Preparedness / Stockpiling
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 nongovernmental 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
Emergency Preparedness / Stockpiling
Strategic National Stockpile
• Repository of
– Antibiotics
– Vaccines
– Immunoglobulins
– Chemical antidotes
– Antitoxins
– Life-support medications
– IV administration
– Airway maintenance
supplies
– Medical/surgical items
Emergency Preparedness / Stockpiling
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
Emergency Preparedness / Stockpiling
Containers designed to
facilitate shipping by
highways and railways.
And also by airways.
Emergency Preparedness / Stockpiling
SNS Program
Delivery 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
Emergency Preparedness / Stockpiling
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.
Emergency Preparedness / Stockpiling
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.
Emergency Preparedness / Stockpiling
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
Emergency Preparedness / Stockpiling
Instructions
for deploying
the SNS Push
Package
NYC Drill Mass Dispensing function - deployment
Emergency Preparedness / Stockpiling
Emergency Preparedness / Stockpiling
Emergency Preparedness / Stockpiling
•350,000 “patients”
•Local supply now
• 3400 Cipro
• 1 b.i.d. x 7 days
• Can only treat 200?
Emergency Preparedness / Stockpiling
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!
Emergency Preparedness / Stockpiling
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
Emergency Preparedness / Stockpiling
Post-exposure Prophylaxis
Bacteria
Anthrax
Plague
Tularemia
1st choice
Alternatives
Ciprofloxacin
Doxycycline
rifampin, penicillin,
ampicillin, chloramphenicol,
clindamycin, and
clarithromycin.
Doxycycline
Ciprofloxacin
Doxycycline
Ciprofloxacin
Emergency Preparedness / Stockpiling
Chloramphenical
Treatment
Bacteria
1st choice
Alternatives
Anthrax
Ciprofloxacin
Doxycycline
rifampin, vancomycin, penicillin,
ampicillin, chloramphenicol, imipenem,
clindamycin, and clarithromycin.
Plague
Gentamicin
Streptomycin
Doxycycline, Ciprofloxacin
Chloramphenical
Tularemia
Gentamicin
Streptomycin
Emergency Preparedness / Stockpiling
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
Emergency Preparedness / Stockpiling
What about contraindications?
1.
2.
3.
4.
Isn’t ciprofloxacin bad for kids?
Isn’t same true for doxycycline?
What if patient is pregnant? Or
breastfeeding
Drug Interactions?
Emergency Preparedness / Stockpiling
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.
Emergency Preparedness / Stockpiling
Contraindications
• ALL contraindications need to be
reassessed in the event of a bioterrorism
event.
Emergency Preparedness / Stockpiling
Special Populations Issues
Pediatrics
• 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)
Emergency Preparedness / Stockpiling
Special Populations Issues
Pregnancy
• 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)
Emergency Preparedness / Stockpiling
Special Populations Issues
Geriatrics
• 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
Emergency Preparedness / Stockpiling
What if this were toxins or
chemicals?
• Decontamination
• Supportive care
• Anti-toxin when available
– Botulism: depending on serotype
• Investigational vaccines:
– Botulism
Emergency Preparedness / Stockpiling
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
Emergency Preparedness / Stockpiling
Emergency Preparedness / Stockpiling
Emergency Preparedness / Stockpiling
“Aging”
Name
Synonym
Aging T1/2
Sarin
GB
~5 hours
Soman
GD
~2 min
Tabun
VX
GA
None
>40 hours
>40 hours
Emergency Preparedness / Stockpiling
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
Emergency Preparedness / Stockpiling
Cyanide Treatment
• Remove from source
• Oxygen
• Cyanide antidote kit
Emergency Preparedness / Stockpiling
NO ONE
able to
walk and talk is in
immediate danger of loss
of life
Emergency Preparedness / Stockpiling
Toxins
• Decontamination
• Supportive care
• Anti-toxin when available
– Botulism: depending on
serotype
• Investigational vaccines:
– Botulism
Emergency Preparedness / Stockpiling
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
Emergency Preparedness / Stockpiling
Agents for Radiation Exposure
•
•
•
•
Potassium Iodide
Ca-DTPA, Zn-DTPA
Prussian Blue
Supportive Care
Emergency Preparedness / Stockpiling
Radioiodines and Thyroid Cancer
Radioiodines concentrate
In the thyroid gland and
can increase the risk of
thyroid cancer
Emergency Preparedness / Stockpiling
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
Emergency Preparedness / Stockpiling
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
Emergency Preparedness / Stockpiling
Emergency Preparedness / Stockpiling
Specific Therapy
Radionuclide
Therapeutic Approach
Tritium
Dilution (force fluids)
Iodine-125 or I-131
KI, or SSKI
Cesium-134 or cesium137
Prussian blue
Strontium-89, or 90
Decrease abs
(antacids), blockage
(strontium lactate),
displacement (oral
phosphate), mobilization
(ammonium chloride)
Plutonium
Zn or Ca (-DTPA)
Emergency Preparedness / Stockpiling
So now that we know
what to do, we will be
alright, right?
Emergency Preparedness / Stockpiling
Emergency Preparedness / Stockpiling
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
Emergency Preparedness / Stockpiling
Chempack
Emergency Preparedness / Stockpiling
Return
Emergency Preparedness / Stockpiling
This completes the current
presentation.
Emergency Preparedness / Stockpiling