40th annual ashp midyear clinical meeting and exhibits december 6, 2005 operational pandemic...
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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