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Iowa Pharmacists Dispense From Strategic National Stockpile During Drill

Donna Young

Counseling victims of a disaster about their medications while wearing a protective respirator mask is arduous, said pharmacist Tim Cmelik, chief of pharmacy services for the Veterans Affairs (VA) Central Iowa Health Care System in Des Moines.

But taking precautions, such as wearing protective equipment, is necessary when health care workers are treating patients that have been exposed to an undetermined agent, bacteria, or virus, he said.

"You want to be effective in providing necessary information, but you also have to protect yourself," he said, referencing the numerous cases of health care workers who fell ill to severe acute respiratory syndrome after unprotected contact with patients infected with the virus.

"Wearing the mask was a different and difficult experience. You have to talk a little louder and slower so that everything is clear and not muffled."

Cmelik participated in April with several other Iowa pharmacists, health care workers, rescuers, law enforcement personnel, and public health officials in the state’s first large-scale disaster drill.

The three-day exercise was Iowa’s first opportunity to test dispensing from the Strategic National Stockpile, a federal repository of antiinfectives, chemical antidotes, antitoxins, life-support medications, i.v. administration and airway maintenance supplies, surgical items, and other medical supplies.

An affected state can request the deployment of the stockpile from the Department of Homeland Security.

Tom Ridge, secretary of Homeland Security, has the authority, in consultation with the secretary of Health and Human Services, the Surgeon General, and the director of the Centers for Disease Control and Prevention (CDC), to order the deployment of the stockpile.

The stockpile is designed to supplement state and local public health agencies in the event of a biological or chemical terrorism incident anywhere and at anytime in the United States or its territories, according to CDC.

The Homeland Security Act of 2002 transferred ownership of the stockpile, formerly known as the National Pharmaceutical Stockpile, from CDC to Homeland Security, according to a CDC spokesperson.

But CDC still manages and coordinates procurement of the stockpile’s contents.

The stockpile has 12 push packages, 50-ton containers of drugs and supplies, which are kept in environmentally controlled secured warehouses in secret locations around the country and are ready for deployment to reach any affected area within 12 hours of a federal decision to distribute the supplies.

For training exercises, Homeland Security does not deploy real stockpile supplies, but sends a training, education, and demonstration (TED) package that simulates the contents of a push package.

Before a state can test and process TED packages, it must first develop a plan for receiving, distributing, and dispensing the medications and supplies, and submit a training and exercise plan to the federal government, according to a CDC spokesperson.

The plan must be reviewed by a Strategic National Stockpile program services consultant who confirms that the plan’s components are in place and workable, according to CDC.

Iowa formed a planning team in October 2002 to prepare for its April 22–24 emergency-preparedness drill, said Jenise Dahlin, logistics officer for Iowa’s Center for Disaster Operations and Response.

Iowa was one of the first states to test deployment of a stockpile TED package, according to Von Roebuck, CDC spokesperson.

Four other states have held drills in which dispensing from the stockpile was tested: Nevada, March 2002; Oklahoma, April 2002; Arizona, November 2002; and Florida, February 2003.

A TED package was deployed in May to Chicago, Illinois, during TOPOFF 2, a $16-million counterterrorism drill conducted in Illinois and Seattle, Washington.

Iowa’s drill involved a three-day release of a biological agent by a fictitious international terrorist organization at a state basketball competition, Dahlin said.

The scenario called for patients to begin showing up at physician offices, clinics, and hospitals with symptoms of an unknown illness that was eventually identified as pneumonic plague.

Federal officials deployed the stockpile’s contents to a secure, undisclosed location using semitrailer trucks for the drill, Dahlin said.

The federal stockpile program deployed 14 staff members—a combination of technical advisers and observers—for Iowa’s drill, according to a CDC spokesperson.

The state’s emergency-preparedness plan includes having a total of 25 key locations, called distribution nodes, where stockpile supplies are strategically delivered throughout the state, Dahlin said. The plan also calls for up to 300 dispensing sites, locations where patients are evaluated and provided with medications.

Public health officials from Polk County, Iowa’s largest county, oversaw arrangements for the dispensing site used for the April drill, she added.

Polk County’s dispensing site, Dahlin said, also acted as a training venue for health officials from the state’s other 98 counties.

About 400 public health staff from Iowa’s 99 counties volunteered as patients during the dispensing portion of the drill, said Dahlin, adding that most of the volunteers were designated as asymptomatic and dispensed empty prescription bottles simulating preventive treatments such as doxycycline or ciprofloxacin.

"The biggest role is staffing the dispensing sites," she said.

In the event of a real statewide disaster, said Iowa Pharmacy Association (IPA) Vice President Nancy Bell, state officials estimated that each of the 300 dispensing sites would need up to eight pharmacists to dispense medications and counsel patients.

Bell participated in planning the drill and helped rally local pharmacists for the exercise.

"My role was helping the state as they planned [the drill] and always assuring them that I was the source for pharmacist volunteers," she said.

IPA coordinates a list of pharmacists that state and county health officials could contact in the event of a disaster when pharmacy services are needed, Bell said.

The association also helps coordinate volunteers for the National Pharmacy Response Teams, she added.

VA’s Cmelik said he got involved because he was interested in discovering how deployment of the Strategic National Stockpile would coincide with the VA disseminating its own bioterrorism stockpile.

VA medical centers are provided two-day supplies of drugs and emergency equipment to treat up to 2000 patients in the event of a disaster, he said.

The VA’s cache of medications and supplies is available to anyone, including nonveterans, who come to a VA medical center for treatment in times of disaster, Cmelik said.

The drill helped Iowa residents discover "where the state was in terms of emergency preparedness," said Doug J. Fitzgerald, a VA staff pharmacist.

Residents in the state, he said, have experienced natural disasters such as tornadoes and floods.

"But there is much more anxiety when you are dealing with something unknown, like a biological agent," he said.

During the drill, Fitzgerald said, many of the volunteer patients acted out symptoms of panic and psychosis.

Some patients were asking for additional bottles of medications and pharmacists had to determine whether a patient’s claim that he or she had family members at home who were unable to pick up the needed preventive drugs themselves was legitimate or that a patient was intending to hoard drugs out of fear and panic, Cmelik said.

"It was a good test of what you would expect to happen when patients get hysterical in a real disaster," he said. "It was a good learning experience."