10/29/2004

Pittsburgh Poison Center Is Terrorism Response Leader

Kate Traynor

If disaster strikes southwestern Pennsylvania, the Pittsburgh Poison Center at Children's Hospital of Pittsburgh is ready to aid in the recovery effort.

Edward P. Krenzelok, professor of pharmacy and pediatrics at the University of Pittsburgh and director of the poison control center, said that the center was involved in disaster-response planning well before the September 11, 2001, terrorist attacks.

The poison center in 1998 was part of the newly formed Pennsylvania Region 13 Working Group, which was convened by emergency-response managers from a dozen counties and the city of Pittsburgh to develop a cooperative approach to responding to terrorist attacks. A 13th county joined the group in 1999. Region 13's approach to counterterrorism has earned national praise and serves as a model for counterterrorism planning.

Today, Pennsylvania has nine regional counterterrorism task forces encompassing the entire state, with Region 13—now called the Southwestern Pennsylvania Emergency Response Group—responsible for its original territory.

Should a biological or chemical attack occur, Krenzelok said, a major role for the Pittsburgh Poison Center will be to manage "the regional cache of medications for first responders." He said the cache is designed to "help get through the initial period of time" before medications from the Strategic National Stockpile become available at the scene of the disaster.

"In southwestern Pennsylvania," Krenzelok said, "we actually contracted with a wholesale drug supplier to have our drugs in a cache. We paid for them, and they are rotated through [the wholesaler's] regular stocks. . . . So our drugs will never expire."

Krenzelok noted that "other places in the country now have used the model that was developed here" to create and manage their own drug stockpiles.

After a biological or chemical attack, the poison control center would also disseminate information on managing exposures to biological or chemical agents and could collect surveillance data to help guide emergency responders.

"In a time of crisis, I think the poison center is a place that can be a resource to pharmacies, to emergency departments, to a lot of people," Krenzelok said. "We can answer the questions, and we can give direction and help them out with understanding" exposure-related issues.

Manning the phones. Even when times are tranquil, the poison control center is a hub of activity. The center serves about 6 million state residents, providing general information about poisons as well as postexposure advice.

Krenzelok said the center operates 24 hours a day and typically gets "about 300 calls a day," or well over 100,000 calls annually.

During the 2001 anthrax attacks, Krenzelok said, "we were receiving, on some days, in excess of 60 extra calls a day just dealing with anthrax."

"Everybody was finding white powder on everything," Krenzelok recalled. "There had always been white powder there, but all of the sudden they recognized it and thought it was anthrax, whether it was on a roll of toilet paper, or in some packing material, or in a prescription" bottle.

Krenzelok said the anthrax attacks rattled health professionals as well as the general public. Part of the poison center's role, he said, was to "demystify" the risks and convey to callers that "chances are, this is not an anthrax exposure, [but] this is what you should do if you think that it is."

He said that other poison centers in the country should incorporate terrorism-response planning into their activities.

"A lot of poison centers don't view themselves as being people with expertise when it comes to biological terrorism," Krenzelok explained. "Well, where's the public going to call? They call poison centers, generally. They may call their physician, they may call their emergency department, they may call or run into their community pharmacist or their hospital pharmacist . . . but usually, they call the poison center."

A history of outreach. The Pittsburgh Poison Center has a long history of proactive involvement with the community and health care professionals. The center is home to "Mr. Yuk," the green-faced icon created in 1971 to keep children away from dangerous household chemicals. The poison control center continues to distribute millions of Mr. Yuk stickers throughout the country each year, along with other poison-education materials for consumers.

During the mid-1990s, Krenzelok said, the poison center "took the lead" in publicizing the dangers of carbon monoxide poisoning and promoting the use of carbon monoxide alarms to protect the public from this threat. Krenzelok is the lead author of a 1996 report in the American Journal of Emergency Medicine on carbon monoxide poisonings and has published extensively on other issues relating to poisoning. He is the author of the 2003 publication Biological and Chemical Terrorism: A Pharmacy Preparedness Guide, which was produced by ASHP through an unrestricted educational grant from AstraZeneca.

A recent report to which Krenzelok contributed deals with the production of mass doses of atropine, which is an antidote to acetylcholinesterase inhibitors, like sarin, that could be used by terrorists.1

"Hospital pharmacists," Krenzelok said, "can't possibly be making 2000 [atropine] doses extemporaneously. It will basically slow your operation down so you can't meet all the other needs that you have to meet" during the crisis.

Krenzelok said his study showed that sterile atropine can be quickly and easily prepared in bulk in i.v. bags to treat many patients during an emergency. According to the report, atropine sulfate 1 mg/mL in 0.9% sodium chloride injection was stable in 100-mL i.v. bags for at least three days at various temperatures. Krenzelok noted that preparing atropine injection in bulk this way is inexpensive, and the i.v. bags consume much less shelf space than does an equivalent amount of the prefilled syringes.

In addition to publishing in scientific journals, Krenzelok said he and his staff have prepared simple, one-page guidelines for responding to biological and chemical threats.

"If there is an event," he said, "we can get [the guidelines] out either electronically via e-mail or fax them to all the hospitals . . . in our service area."

Planning for an event. Krenzelok said pharmacy is a critical component of any counterterrorism plan.

"For the most part," he said, "all of the different biological, chemical, or even radiological terrorism events that could conceivably happen . . . will need the resources of pharmacy to manage patients."

"It's not like you're going to get through an organophosphate nerve-agent-type poisoning without using antidote," Krenzelok explained. "You won't get through an anthrax incident without using antibiotics."

He urged pharmacists to learn about managing responses to terrorist threats, participate in hospital-based emergency-preparedness activities and regional drills, and become active participants in the emergency-response community.

"When there's a disaster, it's not the time to begin to exchange business cards," he said. "The time to do these things is well in advance."

1. Dix J, Weber RJ, Frye RF et al. Stability of atropine sulfate prepared for mass chemical terrorism. J Toxicol Clin Toxicol. 2003; 41:771-5.


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