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7/20/2004

CDC Briefs Communities About Mass Dispensing

Donna Young

Even though all other emergency plans may work flawlessly, if a community cannot rapidly dispense medications to its population after a bioterrorism attack, lives may be lost, said Curtis Mast, exercise coordinator for the Strategic National Stockpile (SNS)a national cache of antiinfectives, chemical antidotes, vaccines, and medical supplies that can be promptly deployed anywhere in the United States or its territories.

Mast made his comments during a Centers for Disease Control and Prevention (CDC) training course for SNS local and state planners, which was broadcast by satellite and on the Web on June 24.

A rebroadcast of the course is available on CDC's Web site at www.phppo.cdc.gov/phtn/webcast/antibiotic/default.asp.

The Clinton administration developed the SNS in 1999 to provide an inventory of medications and medical supplies to supplement and resupply states and local public health agencies in the event of a large infectious disease outbreak or other public health emergency, including a bioterrorism attack.

State and local planners' readiness to provide medications to a community is vital to the nation's overall emergency preparedness efforts, Mast said.

"Mass dispensing is where the rubber meets the road during a bioterrorism attack," he declared. "Dispensing medications is the most complex and perhaps the most important of all SNS planning functions."

In the event of a bioterrorism attack, life-saving pharmaceuticals, antidotes, medical supplies, and equipment need to be distributed in time "because the clock starts ticking when an agent is introduced to a population," Mast warned.

If a community attacked by a bioterrorism event includes a million or more people, "each day's delay in penetrating the area with antibiotics could translate into thousands, if not tens of thousands, of deaths," declared William F. Raub, principle deputy assistant secretary of public health emergency preparedness for the Department of Health and Human Services.

"The longer we take to distribute the antibiotics, the more people will die," he said.

SNS assets can reach any area in the United States in 12 hours or less from the time a decision is made to deploy the supplies, Mast said.

FDA approves first anthrax test

FDA has approved the first test for detecting antibodies produced by Bacillus anthracis, the bacterium that causes anthrax, according to the Centers for Disease Control and Prevention (CDC).

The Anthrax Quick ELISA test was developed by Immunetics Inc. of Boston, Massachusetts, and funded by CDC.

"The approval shows how cooperative work between government agencies and industry can lead to the development of diagnostic tests for biothreat agents and emerging infectious diseases," CDC said in a statement.

The test helps confirm a diagnosis of anthrax by demonstrating that a person's immune system has responded to a protein produced by the infecting bacterium, according to CDC.

The test can be completed in less than one hour, compared to about four hours for previous testing methods, the agency stated.

Before FDA's approval of the Anthrax Quick ELISA test, very few laboratories, other than those run by CDC or the U.S. Army, had the ability to test blood for antibodies to anthrax.

According to CDC, the test will be available "shortly" for use in state and private laboratories.

In 2001, B. anthracis spores were found in letters sent to New York, Florida, and Capitol Hill in Washington. Five people died, and 22 people were sickened.

A state's governor can request CDC to send SNS materials with or without a presidential disaster declaration, he noted.

Dispensing sites. SNS planners should pick points of dispensing (PODs) that are familiar to a community's population, Mast said, such as schools, malls, voting locations, or other commercial buildings.

The American Red Cross has identified for most communities sites that can be used as shelters, which could also be used as PODs, he added.

When scouting for potential PODs, Mast said, planners should consider accessibility for people with impaired mobility.

SNS planners, he added, should also consider what forms of transportation people will use to get to PODs. For instance, in rural areas, most people will travel to a dispensing site by automobiles, but in urban settings, residents might use subways or buses.

A Midwest approach. LuAnne McNichols, bioterrorism clinical coordinator for the Minnesota Department of Health, said her state used geographic information systems to determine the number of people who could be treated at each POD in Minnesota, which has heavily populated and rural regions.

In the densely populated metro region of MinneapolisSt. Paul, which includes seven counties, planners were able to establish dispensing sites so that residents did not have to travel more than 10 miles, she said.

But in the state's rural regions, where it is even more crucial to plan for travel to a POD, planners had to make a "reasonable commute decision" for their populations or use mobile dispensing units instead of PODs, McNichols said.

What is needed. At a minimum, Mast said, PODs should have electricity, heat and air conditioning, water, adequate toilets, a parking area, material handling equipment, and a receiving area for supplies that is out of public view.

Every POD must have some sort of security for asset and staff protection and to help direct traffic and maintain civil order, he said.

"Keep in mind that law enforcement officers are a valuable but limited resource," Mast said.

Planners may need to arrange for help from the National Guard, private security companies, or the United States Marshall Service, he added.

Separate or together. SNS planners must decide whether to use a segmented dispensing operationin which preprophylaxis activities are separated from the actual dispensing of medicationsor a nonsegmented operation.

In a segmented operation, people are screened, triaged, and provided educational materials in one location and transported in groups to the dispensing site to receive medications.

Benefits to a segmented approach, Mast said, include reduced parking and traffic congestion at the dispensing site, tighter security, a potentially decreased number of the "worried well," and a better ability to regulate the flow of people into the POD.

But, he noted, by using a segmented approach, planners must consider additional logistical issues, such as the need for buses, drivers, and fuel and the added cost for those items.

In the nonsegmented approach, all aspects of POD operations are conducted at one location, Mast said.

"A challenge of this approach is how to fairly distribute the public equally among all POD sites," he said.

Another drawback in using a nonsegmented operation is parking problems, Mast said.

"One of the things that the SNS program discovered during our research was that the number of abandoned cars increased proportionally to the attack rate of the illness," he explained. "Once you screen someone out of the crowd as being sick and transport them to the hospital, you have an abandoned car. How would you handle this? Are you planning to use tow trucks?"

One way to avoid abandoned cars, Mast said, is to perform triage while people are in their cars by greeting, quickly examining, and sending sick people to the hospital in their own cars.

The choice of which approach to usesegmented or nonsegmenteddepends on the available resources and policy decisions in a community, Mast said.

Holding disaster drills can help a community determine what type of operation is better to use, he added.

A model approach. An effective POD design addresses the needs of three potential patient groups, said Nathaniel Hupert, assistant professor of public health and medicine at Weill Medical College of Cornell University in New York City: (1) no complicationsotherwise healthy people requiring prophylaxis; (2) complicatedpeople with preexisting illnesses or complicated medical histories; and (3) acutepeople suffering from an acute or life-threatening illness due to the attack.

"Our primary clinic goal for healthy patients or those with no complications is to get them antibiotics quickly," he said. "For complicated patients, the key is to determine contraindications and/or dosage adjustments and then to get them the correct antibiotics quickly. For acute patients, the goal is to identify them at the POD and get them to a health care facility where they can get more advanced care quickly."

Hupert and his research team designed the Weill-Cornell Bioterrorism and Epidemic Outbreak Response Model (BERM), an interactive planning tool designed to estimate the number of PODs needed in a community and the amount of staff required to operate them.

The BERM tool is accessible free online at www.hospitalconnect.com/aha/key_issues/disaster_readiness/resources/vaccination.html.

Volunteers are needed. A trained volunteer staff is critical to a successful POD operation, Mast said.

Volunteers can be divided into two groups: those who can be recruited and trained before an event and the spontaneous volunteers that may show up to help during an event.

In Minnesota, McNichols said, volunteer recruitment is being planned through a statewide registry, and a number of counties already have Medical Reserve Corpsa federally funded program designed to provide organization, structure, and training for licensed health care professionals who want to volunteer in their local communities.

Pharmacists and pharmacy students and technicians may volunteer to respond to bioterrorism events or other public health crises by serving as a member of a National Pharmacist Response Team (NPRT).

An NPRT is assigned to each of the 10 Department of Homeland Security (DHS) regions to assist in mass prophylaxis or vaccination of Americans.

Members of NPRTs are paid a salary when activated, reimbursed for travel and per diem expenses, and have professional liability coverage outside their state of licensure.

The Joint Commission of Pharmacy Practitioners Working Group, of which the American Society of Health-System Pharmacists is a member, is sponsoring the program in cooperation with DHS.

Applications are available at ndms.fema.gov/nprt.html.