Emergency Preparedness / Stockpiling

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Emergency Preparedness / Stockpiling
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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

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Rashes
A tentative diagnosis of plague is made
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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?

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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

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Question 2) AnswerPills 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 gt 7 days of Cipro or
  Doxycycline
• 4.9 million doses
• Clearly exceeds local supply
• What plans currently exist for such a disaster?

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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

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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 nations
  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

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Strategic National Stockpile

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

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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

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

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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.

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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.

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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

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Instructions for deploying the SNS Push Package
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NYC Drill Mass Dispensing function - deployment
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• 350,000 patients
• Local supply now
• 3400 Cipro
• 1 b.i.d. x 7 days
• Can only treat 200?

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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!

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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

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Post-exposure Prophylaxis
Bacteria 1st choice Alternatives
Anthrax Ciprofloxacin Doxycycline rifampin, penicillin, ampicillin, chloramphenicol, clindamycin, and clarithromycin.
Plague Doxycycline Ciprofloxacin Chloramphenical
Tularemia Doxycycline Ciprofloxacin
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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 Doxycycline, Ciprofloxacin, Chloramphenicol
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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

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What about contraindications?

1. Isnt ciprofloxacin bad for kids?
2. Isnt same true for doxycycline?
3. What if patient is pregnant? Or breastfeeding
4. Drug Interactions?

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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.
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Contraindications

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

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Special Populations IssuesPediatrics

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

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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)

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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

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What if this were toxins or chemicals?

• Decontamination
• Supportive care
• Anti-toxin when available
• Botulism depending on serotype
• Investigational vaccines
• Botulism

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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

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Aging
Name Synonym Aging T1/2
Sarin GB 5 hours
Soman GD 2 min
Tabun GA gt40 hours
VX None gt40 hours
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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
  

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Cyanide Treatment

• Remove from source
• Oxygen
• Cyanide antidote kit

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Cyanide Antidote Kit

• Amyl nitrite perle until IV
• Sodium Nitrite (300mg IV)
• Peds 0.33 ml/kg of 10 solution)
• Sodium Thiosulfate (12.5gm IV)
• Peds 1.65 ml/kg of 25 solution)

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

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Toxins

• Decontamination
• Supportive care
• Anti-toxin when available
• Botulism depending on serotype
• Investigational vaccines
• Botulism

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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
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Agents for Radiation Exposure

• Potassium Iodide
• Ca-DTPA, Zn-DTPA
• Prussian Blue
• Supportive Care

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

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Dosage (KI)
Age Group Dosage
Infants lt 1 month 16 mg
Children 1 month 3 yrs 32 mg
Children 318 yrs 65 mg
Adults 130 mg
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Specific Therapy
Radionuclide 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)
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So now that we know what to do, we will be
alright, right?
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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

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Chempack
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Return
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This completes the current presentation.