COUNTER -TERRORISM Stephanie Baker Justice, PharmD, BCPS ...neahec.org › Uploads › files ›...

COUNTER-TERRORISMTHE ROLE OF THE PHARMACIST

Stephanie Baker Justice, PharmD, BCPSDirector, Pharmacy ServicesDirector, PGY1 Pharmacy ResidencySt. Claire [email protected]

DISCLOSURES

Dr. Justice has no relevant financial relationships or conflicts of interest with regards to materials or products presented during this presentation

OBJECTIVES

Describe the pharmacist’s role in counter-terrorism planning

Identify the chemical and infectious agents most likely to be used in a bioterrorism event

List antidotes and therapies for the most likely threats

Apply scenario based planning in estimating counter-terrorism pharmaceutical needs in your community

COUNTER-TERRORISM

Proactive

Planned

Prepared

Definitive action

Response driven

CDC Emergency Response Resources

THE PHARMACIST’S ROLE


CHEMICAL ATTACK

Chemical agent Substance intended for use in military operations to kill, seriously injure, or incapacitate humans through its toxicological effects

World War I 150 tons of chlorine 800 deaths and the retreat of 15,000 Allied troops

2 years later Sulfur mustard: 20,000 casualties

Iran-Iraq War Mustard and nerve agents


MATSUMOTO, JAPAN-1994

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1995-TOKYO SUBWAY

5,500 exposed

3,227 seeking

care

550 transported

by EMS

641 arrive at St. Luke’s

1995-TOKYO SUBWAY

20% of hospital personnel were affected

No patients were decontaminated

CHEMICAL DECONTAMINATION

Decontamination of mass chemical casualties is best handled with water or soap/water

Decontamination facilities are best located outside the hospital in an area such as a parking lot

No one who is potentially contaminated should be allowed to enter the hospital

If a hospital is contaminated, it must be shut down and prevented from treating victims


CHEMICAL DECONTAMINATION

CHEMICAL AGENTS

Nerve agents Sarin, tabun, soman, cyclosarin, methylphosphonothioic acid

Vesicants Sulfur mustard, lewisite, nitrogen mustard, phosgene oxime

Cyanides Hydrogen cyanide, cyanogens chloride

Pulmonary Agents Chlorine, phosgene, diphosgene, chloropicrin


NERVE AGENTS

Signs Pinpoint pupils, bronchoconstriction, respiratory arrest, hypersalivation, increased secretions, diarrhea, seizures, confusion

Treatment Atropine 2mg IM/IV every 5 mins Pralidoxime 600 – 1,800 mg IM or 1 gm IV over 20 – 30mins Repeat as needed based on symptoms


Sarin Soman Tabun VXHousehold

Organophosphate

Aging time 5 hours 5 minutes 14 hours 48 hours 12 – 24 hours

Dermal LD50 1,700 mg 100 mg 1,000 mg 10 mg >35,000 mg

Inhaled LCt50 100 mg/m3 50 mg/m3 400 mg/m3 10 >250 mg/m3

Volatility High High High Low Very low

Environmental persistence

Low Low Low High Intermediate

PROPERTIES OF NERVE AGENTS

J Pharm Bioall Sci 2010; 2:166-178

VESICANTS

Signs Asymptomatic latency period, skin erythema and blistering, watery swollen eyes, metabolic failure, bone marrow suppression

Treatment Mustards: no antidote Lewisite: British anti-lewisite Supportive therapy for burns


CYANIDES

Signs Metabolic acidosis, hypotension, pink skin color, coma, seizures, respiratory and cardiac arrest

Treatment Sodium thiosulfate 12.5 mg IV plus Hydroxocobalamin 5 – 10 gm IV


PULMONARY AGENTS

Signs Pulmonary edema, acute respiratory distress syndrome, noncardiogenic pulmonary edema, pulmonary infiltrates

Treatment No antidote Manage secretions


CASE #1

A young couple was transported to your ED from a localcinema. You have been told that many others are in route.The 18 year old male and 17 year old female presentfollowing intubation. They are unresponsive, diaphoretic,they have constricted pupils with excessive lacrimation,vomiting, diarrhea, and restlessness. The young man hada seizure. Copious amount of secretions have beensuctioned from them.

CASE #1

1. What should be your immediate intervention?

2. What needs to be done to accommodate other victims?

BIOTERRORISM

Natural epidemics vs bioterrorismDifference is intent

In both instances a disease may be transmissible from person to person (smallpox) or non-transmissible (anthrax)

The approach to controlling the event depends on the agent, not on the initial cause


INFECTION CONTROL

The use of measures to prevent the transmission of infectious agents in healthcare settings

Standard precautions apply to all patients and include hygiene, use of gloves, gown, mask, eye protection, or face shield

Three categories of transmission based precautions: contact, droplet, and airborne


CONTACT PRECAUTIONS

Intended to prevent transmission of infectious agents that are spread by direct or indirect contact with an affected patient or the patient’s environment

Include wearing a gown and gloves for all interactions that may involve contact with the patient or potentially contaminated areas of the patient’s environment


DROPLET PRECAUTIONS

Intended to prevent transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions

They include wearing a mask in addition to taking contact precautions


AIRBORNE PRECAUTIONS

Prevent transmission of infectious agents that remain infectious over long distances when suspended in air

In addition to observing contact precautions, healthcare workers wear a high-filtration (N-95 or better) mask or respirator, depending on the disease-specific recommendations


ISOLATION AND QUARANTINE

Isolation is the separation of persons who are known to have a contagious disease

Quarantine is the separation of those who have been exposed to a contagious disease but who may or may not become illThis may extend beyond people to buildings, animals, cargo, etc.


CATEGORY A AGENTS

Possess both a high potential for adverse public health impact and a serious potential for large-scale dissemination and thus are high priority agents Anthrax Smallpox Plague Botulism Tularemia Viral hemorrhagic fevers


2001: 22 CASES OF ANTHRAX

ANTHRAX

Disease occurs when the spore form of anthrax is introduced subcutaneously or via inhalation

Three syndromes occur with anthrax: Cutaneous-most common Gastrointestinal Inhalation

Treatment Ciprofloxacin, doxycycline, and penicillin


SMALLPOX

Eradicated worldwide in 1977

2 forms-variola major and variola minor

Very contagious-lesions and respiratory secretions

Mortality of 20%

Only 2 stockpiles remain: CDC/Russian

TreatmentLargely supportive


PLAGUE (YERSINIA PESTIS)

A zoonosis that primarily affects rodents

Transmitted to humans by bites from infected fleas, scratches or bites from infected animalsCan be aerosolized

Three clinical syndromes:Bubonic (80 – 90%)Septicemic (10%)Pneumonic (rare)

TreatmentStreptomycin (limited availability)Gentamicin or doxycycline or ciprofloxacin


BOTULISM

Neurotoxin produced by Clostridium botulinum

Three forms: foodborne, wound and infant

Oral lethal dose estimated to be 1 ng/kg

May be released as a form intended to be ingested or as an aerosol

TreatmentToxin neutralization with an equine trivalent antitoxin


CATEGORY B AGENTS

Moderately easy to disseminate and have lower mortality rates than Category A agents Brucellosis Epsilon Toxin of Clostridium perfringens Food safety threats (e.g., Salmonella, E. Coli, Shigella) Glanders Meliodosis Psittacosis Q fever Ricin toxin Staphlococcal enterotoxin B Typhus fever Viral encephalitis


CATEGORY C AGENTS

Includes emerging pathogens that could be engineered for mass dissemination in the future Nipah virus Hantaviruses Tickborne hemorrhagic fever viruses Tickborne encephalitis viruses Yellow fever Multi-drug resistant tuberculosis


ANTHRAX SCENARIO

Dissemination of anthrax powder at a UK basketball game

24,000 people exposed

Need to provide antibiotics3 day local supply60 day NPSDoxycycline selected as initial drug of choice100 mg PO BID x 3 days, then 57 day follow-up24,000 x 3 x 2 = 144,000 capsules needed


ANTHRAX SCENARIO

Dispensing containerZip lock bags: 24,000

Dispensing records

Drug information sheets: 24,000

Adaptation of dosing for pediatrics

Temporary distribution sites requiredMust be located away from the hospital

Volunteer staff requiredMust be trained

STRATEGIC NATIONAL STOCKPILE (SNS)

Established in 1999 as NPS (National Pharmaceutical Stockpile)

Available to local health departments through federal decision

Contain “push packages” available within 12 – 24 hours of the federal decision


PUSH PACKAGES

Contain pharmaceuticals, IV supplies, airway supplies, bandages and dressings

Among the medications are items such as:doxycycline, ciprofloxacin, gentamicin, dopamine, albuterol, lorazepam, morphine, atropine, diazepam and pralidoxime

Counting machines, volumetric devices, packaging and labeling machines

Written provider and patient information


CHEMPACK

Decentralized Strategic National Stockpile

Established in 2004/2005

EMS and hospital containers

Designed for rapid response to chemical incidents

Designed to treat ~1,000 victims


CHEMPACK EQUIPMENTCHEMPACK Storage Container SENSAPHONE 2050


SNS Program supplies CHEMPACK materials, approved storage containers and monitoring equipment

States provide a secure, environmentally controlled storage area with phone connectivity and assume custody of the pharmaceuticals

STANDARD CONTAINERS


The CHEMPACK Project provides two types of containers:

Emergency Medical Service (EMS) ContainerDesigned for emergency respondersMaterials packaged primarily in auto-injectors

Hospital ContainerDesigned for hospital dispensingWill contain multiuse vials for precision dosing and long term care

WHAT IS VMI?

Vendor Managed Inventory

Designed to be a ‘cushion’ for NPS

Generally will take 24 – 36 hours after the decision has been made to mobilize stock

Usually more specific than NPS (‘tailored’ to the event)


EVERY PHARMACIST SHOULD:ENSURE APPROPRIATE STOCK IS ON HAND

Doxycycline 100 mg Add number of hospital staff and medical staff Multiply by 2 (family coverage) Multiply by 6 (capsules of 100 mg for 3 days BID) i.e. 500 hospital staff, 100 medical staff = 600 600 x 2 x 6 = 7,200 capsules

Quinolone (ciprofloxacin or levofloxacin)¼ of doxycycline supply i.e. 7,200/4 = 1,800 doses

Amoxicillin 1/8 of doxycycline supply i.e. 900 doses



IV forms of drugs listed on previous slides Recommend typical quantities found in hospital pharmacy

Zip lock bags Doxycycline dispensing = 600 Quinolone dispensing = 150 Amoxicillin dispensing = 75 Total bags = 825 bags

Patient information sheets Dual purpose serving as ‘labels’ Quantity as above



Atropine Enough to treat 100 patients 2 mg x 2 doses x 100 = 400 mg Atropine is inexpensive and can be purchased in the powder form, so this amount

should be easily exceeded

Pralidoxime (2-PAM) Enough to treat 25 patients 2 gm x 2 doses x 25 = 100 gm Pralidoxime is expensive but can be purchased in the powder form



Adequate supplies of: Analgesics Benzodiazepines IV fluids Silver sulfadiazine


COUNTER-TERRORISMTHE ROLE OF THE PHARMACIST

Stephanie Baker Justice, PharmD, BCPSDirector, Pharmacy ServicesDirector, PGY1 Pharmacy ResidencySt. Claire [email protected]

COUNTER -TERRORISM Stephanie Baker Justice, PharmD, BCPS ...neahec.org › Uploads › files ›...

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