Marshal Bickert, MPHAssociate Director

Central Ohio Trauma System

Discuss and Review Potential Mass Prophylaxis Scenarios

Discuss and Review National, State , and Local Mass Prophylaxis Processes

Pandemic Influenza Related Mass Prophylaxis- Of Course!

Bioterrorism

Naturally Occurring Infectious Disease Outbreaks

Prevention of Disease Secondary to Natural Disasters

Category A Anthrax Plague Tularemia

Category B Brucellosis Glanders Melioidosis Q Fever

MRSA Meningococcal

Meningitis Haemophilus

influenzae, Invasive Pandemic Influenza

Vector-borne Diseases- Malaria, Lyme Disease

Waterborne Diseases- Cryptosporidium, Strep, Staph

Cutaneous- Strep, Staph

Shelter Sickness

Strategic National Stockpile- CDC

State Stockpiles and SNS Integration

Local Mass Vaccination Clinics/Points Of Distribution MMRS and HRSA Funded Caches Cities Readiness Initiative

Large Quantities of Medicine, Vaccines, Supplies, and Equipment

2 Components 12 Hour Push Pack Vendor Managed

Inventory

12 Hour Push Packs Caches of pharmaceuticals,

antidotes, and supplies On-site within 12 hours

Vendor Managed Inventory (VMI) Shipped within 24-36 hours Flexible and can be tailored

to state/local needs

A pilot program to prepare 21 pilot cities and 15 additional U.S. cities to dispense needed drugs and medical supplies within 48 hours of the decision to do so.

Ohio:ClevelandColumbusCincinnati

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Non-medical model to dispense Use of “push” and “pull” mechanisms to

dispense medications to the masses Rapid activation and response Multi-agency response

• Limited to aerosolized anthrax

• Exposed population difficult to determine

• Community demand for response

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Aerial dispersion of anthrax over a large geographic area can be accomplished with commercially-available equipment..

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1 Day 2 Days 3 Days 4 Days 5 Days 6 DaysImmed.

10 Days 84% 78% 71% 62% 54% 45% 36% 28%

7 Days 95% 91% 85% 78% 69% 59% 49% 39%

6 Days 97% 94% 89% 83% 75% 65% 54% 43%

5 Days 98% 96% 92% 87% 80% 71% 60% 49%

4 Days 99% 98% 95% 91% 85% 76% 66% 54%

3 Days 100% 99% 97% 94% 89% 81% 72% 60%

2 Days 100% 99% 98% 96 92% 86% 77% 66%

1 Day 100% 100% 99% 97% 94% 89% 82% 72%

DELAY in Initiation

DURATIONof Campaign

Anthrax Exposure: Anthrax Exposure: Proportion of Population SavedProportion of Population Saved

1 Day 2 3 4 5 7 Days1 Day 2 Days 3 Days 4 Days 5 Days 6 Days

People leave their homes and go to the site to receive medications

Large employers College campuses Senior living

communities Hospitals Skilled Nursing

Facilities & Assisted Living.

Medications delivered directly to people

Examples: U.S. Postal Service

delivery to homes Medication kits pre-

positioned Independent Courier

Postal Service routinely delivers to each resident daily

Allows to “shelter in place”

Would supplement more traditional dispensing plans

Security Issues

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Information Sheet:

Today in your mailbox you have received a bottle of antibiotics. These antibiotics have been distributed because of a potentially wide scale release of a pathogen in your area. There are risks to your health if you are not treated for this exposure. There are however the risks associated with the antibiotic itself. The following provides guidance for pediatric dosage, and provide instructions for seeking assistance from public health authorities…

USPS will deliver an information sheet & two ‘unit of use’ pill bottle to each residential delivery point (i.e. mail box)

All deliveries will be performed using a postal vehicle

Security personnel will accompany each postal worker during the delivery of the items

Local Point of Dispensing will still be necessary Other delivery methods will likely be necessary

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Delivery of Antibiotics & Instructions

• Drive thru dispensing

• Semi-medical and non-medical PODs

• Law Enforcement

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Health Resources and Services Administration (HRSA) Hospital Bioterrorism Preparedness Program 3 day supply prophylaxis for all hospital

employees and their family members

Metropolitan Medical Response System (MMRS) Caches

Antiviral medications are principally used to treat influenza infections

Under certain circumstances, these drugs can also reduce transmission of the virus or even prevent infection..

Two antiviral drugs are effective against the H5N1 virus in laboratory testing. Tamiflu, Roche Laboratories, administered as

a course of capsules or liquid that is taken orally.

Relenza, manufactured by GlaxoSmithKline, is administered by an inhaler.

Both work by blocking the ability of the virus to multiply beyond the infected host cell.

Treatment with a neuraminidase inhibitor (oseltamivir [Tamiflu®] or zanamivir [Relenza®]) will Decreasing risk of pneumonia, Decrease hospitalization by about half (as shown for

interpandemic influenza) Will also decrease mortality.

Antiviral resistance to the adamantanes (amantadine and rimantadine) may limit their use during a pandemic.

The primary source of antiviral drugs for a pandemic response will be the supply of antiviral drugs that have been stockpiled..

Treating earlier after the onset of disease is most effective in decreasing the risk of complications and shortening illness duration.

35% Attack Rate Number of priority groups that can be covered will be

known at the start of the pandemic No vaccine 4-6 months

Goal: 25% of Population

50 Million Courses in National SNS

31 Million Courses at state level (purchased at federal discounted rate)

Primary constraints: Limited supplies Increasing risk of side effects with prolonged use Potential emergence of drug-resistant variants of the

pandemic strain, particularly with long-term use of M2 inhibitors    

Need will decrease with vaccine availability

Post-exposure prophylaxis might be useful in attempts to control small, well-defined disease clusters (e.g., outbreaks in long-term care facilities

Oseltamivir has demonstrated >70% efficacy as prophylaxis against laboratory-confirmed febrile influenza illness during interpandemic

Prophylaxis with amantadine or rimandatine decreased the risk of influenza illness during the 1968 pandemic and the 1977 reappearance of H1N1 viruses

The number of persons who receive prophylaxis with oseltamivir should be minimized, primarily to extend supplies available to treat persons at highest risk of serious morbidity and mortality. 

If a pandemic virus is susceptible to M2 ion channel inhibitors, amantadine and rimantadine should be reserved for prophylaxis, although drug resistance may emerge quickly.

Rimantadine is preferred over amantadine

Targeting prophylaxis to priority groups: Using post-exposure prophylaxis (generally for 10 days)

to: Control small, well-defined disease clusters, Protect individuals with a known recent exposure

(e.g., household contacts of pandemic influenza patients)

When a vaccine becomes available, post-exposure prophylaxis to protect key personnel during the period between vaccination and the development of immunity. 

Strategies for antiviral prophylaxis may be revised

Increased Workforce Demands

Loss of

Workforce

Extremely High

Census

Internal Factors

•Workplace Acquired Illness

•Morale

•Efficacy

•Fear- Self

•Facility Security

External Factors

•Community Acquired Illness- Self

•Fear- For Family

•Illness Spouse

•Illness Dependents

•Transportation

•Home/Childcare

Increased Needed Output

•High Acuity Illness

•Diminishing Resources

•PPE Requirements

•Security Measures

Catastrophic Workforce Shortages

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Knowledge- Only 11% Personal/Family Preparedness- 28% Spousal Illness Effect- 62% (75%) Dependent Effect- 90% (65%) Dependent Care- 25% (60%)

Top 3 Concerns: If I go to work, I will make my family sick I don’t have enough knowledge to keep myself

safe The proper planning has been done.

Top 3 Recommendations: PPE Training Bird Flu/Pandemic Education Bird Flu/Pandemic Planning

Distribution of state or federal supplies of antiviral drugs

Occurrence of adverse events following administration of antiviral drugs

Effectiveness of treatment and prophylaxis

Development of drug resistance

Mass Prophylaxis Scenarios Bioterrorism Infectious Disease Natural Disasters

Mass Prophylaxis Systems SNS PODS CRI Local Caches

Pandemic Influenza Antiviral Prophylaxis

Marshal Bickert, MPHMBickert@goodhealthcolumbus.org

614-240-7419x4