40th Annual ASHP Midyear Clinical Meeting and ExhibitsDecember 6, 2005

Operational Pandemic Preparedness from a Tertiary Care

Facility on the West Coast

John Zarek, RPh

System Clinical Manager

Cardinal Health Pharmacy Management

Swedish Medical Center, Seattle, WA

Role of Pharmacy

• Ad hoc member of Epidemiology Cmte.• Provide pharmaceutical care perspective on

medication issues• Provide leadership role in assuring needed

pharmaceutical products available within Swedish system

• Provide link to pharmacist at Public Health

Framing Questions

• How should Swedish prepare knowing that there are limited therapy resources?

• Does King County Public Health (KCPH) have plans to depot oseltamivir or how it should be prioritized?

• Does KCPH have recommendations on how local institutions should be prepared?

• How does KCPH view federal support?

Framing Questions

• How much oseltamivir is available in the wholesalers?

• What will Roche do if there is stockpiling?• If there were a pandemic, how many patients

should Swedish plan to treat?• How do we balance treatment of patients with

prophylaxis of health care workers?

Early Public Health ResponsesSeptember, 2005

Oseltamivir: treatment over prophylaxis• Prioritization

– Patients hospitalized with influenza– HCW & EMS workers with direct patient contact– Pandemic health responders, public safety & key

government decision makers– Other high risk populations (undefined)

Early Public Health ResponsesSeptember, 2005

• Prophylaxis if adequate resources– Post-exposure in certain environments– HCW in emergency departments & EMS workers– ICUs and dialysis units– Highest risk outpatients– Other HCW with patient contact

Antiviral Drug DistributionHHS Pandemic Influenza Plan, November, 2005

Priority Groups• Use in treatment in hospitals, clinics, & home

health• Use in post-exposure prophylaxis (direct

contacts of infected patients)• Use in prophylaxis (HCWs, public safety

workers, essential service providers)

Early Public Health ResponsesSeptember, 2005

• Considering feasibility of acquiring a local stockpile of oseltamivir

• Considering a hospital stockpile in accordance with HHS guidelines

• KC healthcare coalition to address medical surge capacity & pandemic response

• KCPH as possible broker to request and receive oseltamivir

Decision to Purchase Oseltamivir

• Treatment versus prophylaxis or both• Contacting Roche• Courses of therapy: 250, 500, 1000?• Anticipated purchase cost: $15-66K• Cardinal Health distribution center inventory• Federal response capability: 72-96 hours?• Integrating influenza treatment with stockpiling

for avian pandemic (ability to handle 1st wave of infected patients)

Clarifying with Roche about Oseltamivir Availability

• US supply chain• Production plans• Product issues• Effectiveness in humans• Benefits of preventative measures• Perception of federal government response to

limited supply

North Carolina Guidelines on Stockpiling

• Strongly discouraged personal stockpiling– No sustained human-to-human transmission in SE

Asia of H5N1 virus– No H5N1 in US/North American poultry– Supplies of oseltamivir are limited and should be

reserved for seasonal influenza– US pandemic plan: use in priority groups– Inappropriate use may lead to resistance

» NC Dept HHS Memorandum October 19, 2005

Washington State Plan

• Assumes limited resources• Maximizes response capabilities with

established partnerships/existing assets• Part of Comprehensive Emergency

Management Plan– Initial phases (inter-pandemic period)– Pandemic alert phase (Currently Level 3)– Elevated pandemic alert stage– Pandemic influenza phase

KCPH Health AdvisoryOctober 17, 2005

• Arguments in favor of personal stockpile– Existing national stockpile is insufficient– Drug is widely available in private sector for

seasonal flu therapy– Private sector supply might not contribute

significantly to a pandemic response– No official recommendations by CDC or HHS

against personal stockpiling

KCPH Health AdvisoryOctober 17, 2005

• Arguments against a personal stockpile– Not recommended in draft national pandemic

preparedness plan– May result in shortages for use in treatment &

prevention of seasonal flu– No pandemic occurring currently– Effectiveness & optimal dose is unknown– Inappropriate use, when to start therapy?– Inequitable distribution

Swedish Plan

• Activate HEICS*: hospital emergency management plan

• Adapt components of North Carolina guidelines & new HHS pandemic plan

• Clarify tasks performed at various alert levels* Hospital Emergency Incident Command System

Swedish Plan

• Coordinate with KCPH and hospital coalition

– application of altered standards of care if mass casualty

• Coordinate with KCPH to prioritize oseltamivir utilization

• Continuous respiratory etiquette, increased screening, decontamination, lock down

Other Issues at Swedish

• Communicating with hospital administration• Sharing the purchasing costs of drugs &

personal protective equipment• Helping Physician Division with stockpiling

issue• Establishing criteria for outpatient use of

oseltamivir• Communicating with hospital information

officers

KCPH Health AdvisoryNovember 23, 2005

Screening & initial management of suspect human cases

• Clinicians asked to take travel history on all radiographically confirmed pneumonia, acute respiratory distress syndrome or other respiratory illness for which an alternative diagnosis is not established

• Compare travel history to list of countries with known avian influenza

KCPH Health AdvisoryNovember 23, 2005

If patient meets clinical/epidemiological criteria for suspected case of H5N1 virus

• Implement infection control precautions• Notify hospital Epidemiology & Public Health• Obtain clinical specimens for state testing• Evaluate alternative diagnoses• Decide on inpatient or outpatient care

(coordinate with home health)• Initiate antiviral treatment within 48 hours of

symptom onset

Today’s Reality

• Effective coordination & communication between pharmacy-Epidemiology-public health-infectious disease

• Continuously changing landscape • Tough choices on who gets treated in the

hospital still to be made if mass casualty event• Uncertainty of HHS response• Reliance on coordinated plan with healthcare

coalition• Reliance on Public Health critical