The Pharmacist’s The Pharmacist’s Role and ResponseRole and Response

September 28, 2005September 28, 2005

Sheeba Samuel, Pharm.D.Sheeba Samuel, Pharm.D.Clinical Assistant ProfessorClinical Assistant Professor

Ernest Mario School of PharmacyErnest Mario School of PharmacyRutgers, The State University of New JerseyRutgers, The State University of New Jersey

Clinical PharmacistClinical PharmacistHackensack University Medical CenterHackensack University Medical Center

ObjectivesObjectives Review the role of government Review the role of government

organizations in disaster management organizations in disaster management Review the role of a pharmacist in Review the role of a pharmacist in

bioterrorism preparation and response as bioterrorism preparation and response as per national pharmaceutical organizationsper national pharmaceutical organizations

Discuss what a pharmacist can do in Discuss what a pharmacist can do in preparation and responsepreparation and response

Discuss methods by which pharmacists Discuss methods by which pharmacists can prepare for a bioterrorism eventcan prepare for a bioterrorism event

Discuss various resources available to a Discuss various resources available to a pharmacistpharmacist

Terminology used in Terminology used in Preparation and ResponsePreparation and Response

MitigationMitigation Measures employed before an incident occurs to Measures employed before an incident occurs to

reduce damagereduce damage PreparednessPreparedness

Activities that are conducted to improve Activities that are conducted to improve readiness before a disasterreadiness before a disaster

ResponseResponse Actions that deal with the consequences during Actions that deal with the consequences during

a disastera disaster RecoveryRecovery

Procedures that help normalize business Procedures that help normalize business operationsoperations

Federal Disaster Response Federal Disaster Response OrganizationsOrganizations

Federal Emergency Management Agency Federal Emergency Management Agency (FEMA)(FEMA)

National Response Plan (NRP)National Response Plan (NRP) National Disaster Medical System (NDMS)National Disaster Medical System (NDMS) Disaster Medical Assistance Teams (DMATs)Disaster Medical Assistance Teams (DMATs) Metropolitan Medical Response System (MMRS)Metropolitan Medical Response System (MMRS) National Pharmacy Response Team (NPRT)National Pharmacy Response Team (NPRT) Centers for Disease Control and Prevention Centers for Disease Control and Prevention

(CDC)(CDC) Strategic National Stockpile (SNS)Strategic National Stockpile (SNS)

Federal Emergency Federal Emergency Management Agency Management Agency

(FEMA)(FEMA) Coordinates responsibility for all disastersCoordinates responsibility for all disasters Provides funding at the request of the Provides funding at the request of the

governorgovernor Assists state and local organizations to Assists state and local organizations to

mitigate, prepare for, respond and mitigate, prepare for, respond and recover from emergenciesrecover from emergencies

Developed the federal response planDeveloped the federal response plan Organizes federal assistance into 12 Organizes federal assistance into 12

categoriescategories Examples: search and rescue, transportation, food, Examples: search and rescue, transportation, food,

health and medical services, communication, etc.health and medical services, communication, etc.

National Response Plan National Response Plan (NRP)(NRP)

Developed as per Homeland Security Developed as per Homeland Security Presidential DirectivePresidential Directive

PurposePurpose Align federal coordination structures, Align federal coordination structures,

capabilities, and resourcescapabilities, and resources GoalGoal

Improve coordination among federal, state, Improve coordination among federal, state, local and tribal organizationslocal and tribal organizations

Template: National Disaster Medical Template: National Disaster Medical System (NDMS)System (NDMS)

National Disaster Medical National Disaster Medical System (NDMS)System (NDMS)

Cooperative effort between 4 agenciesCooperative effort between 4 agencies Department of Health and Human ServicesDepartment of Health and Human Services Department of DefenseDepartment of Defense Department of Veterans AffairsDepartment of Veterans Affairs FEMAFEMA

Partnership between federal and private Partnership between federal and private sectorssectors

Volunteer basedVolunteer based 3 major responsibilities3 major responsibilities

Provide hospital bedsProvide hospital beds Establish Disaster Medical Assistance Teams Establish Disaster Medical Assistance Teams

(DMATs)(DMATs) Establish specialty DMATsEstablish specialty DMATs

Disaster Medical Assistance Disaster Medical Assistance Teams (DMATs)Teams (DMATs)

98 state-based teams98 state-based teams 35 medical and support personnel: 35 medical and support personnel:

physicians, nurses, pharmacists, paramedicsphysicians, nurses, pharmacists, paramedics Process 200-250 patients in 24 hour periodProcess 200-250 patients in 24 hour period 26 considered to be readiness level 1 (R1)26 considered to be readiness level 1 (R1)

Must meet three requirementsMust meet three requirements Be adequately trained and equippedBe adequately trained and equipped Be able to care for themselvesBe able to care for themselves Be fully prepared going into disaster to not Be fully prepared going into disaster to not

add to burden of overwhelming add to burden of overwhelming infrastructureinfrastructure

Disaster Medical Assistance Disaster Medical Assistance Teams (DMATs)Teams (DMATs)

Provide four servicesProvide four services Search and rescueSearch and rescue Triage and initial stabilizationTriage and initial stabilization Provide definitive medicalProvide definitive medical

carecare EvacuationEvacuation

Gaudette R, Schynitzer , George E, Briggs SM. Lessons Learned from the September 11th World Trade Center Disaster: Pharmacy Preparedness and Participation in an International Medical and Surgical Response Team. Pharmacotherapy 2002;22(3):271-81.

Specialty DMATsSpecialty DMATs

TraumaTrauma BurnsBurns PediatricsPediatrics Veterinary Medical Assistance Teams Veterinary Medical Assistance Teams

(VMATs)(VMATs) Disaster Mortuary Operation Response Disaster Mortuary Operation Response

Teams (DMORTs)Teams (DMORTs) National Medical Response Teams National Medical Response Teams

(NMRTs)(NMRTs)

Metropolitan Medical Metropolitan Medical Response System (MMRS)Response System (MMRS)

Public and Private sector agencies Public and Private sector agencies brought together to enhance brought together to enhance emergency preparedness and responseemergency preparedness and response Representatives from local police and fire Representatives from local police and fire

departments, hospitals, professional departments, hospitals, professional organizations, community and state organizations, community and state agencies, and federal groupsagencies, and federal groups

Required to have well-coordinated Required to have well-coordinated plan to respond to emergenciesplan to respond to emergencies

National Pharmacy National Pharmacy Response Team (NPRT)Response Team (NPRT)

Includes pharmacists, pharmacy technicians, Includes pharmacists, pharmacy technicians, pharmacy studentspharmacy students

Goal: assist in chemoprophylaxis or mass Goal: assist in chemoprophylaxis or mass vaccinationvaccination

Become temporary federal employeeBecome temporary federal employee Paid salaryPaid salary Reimbursed for travel and per diem expensesReimbursed for travel and per diem expenses Liability coverage outside of state of licensureLiability coverage outside of state of licensure Deployed for no longer than 2 weeksDeployed for no longer than 2 weeks

Required to complete web-based training program, Required to complete web-based training program, be current with treatment recommendationsbe current with treatment recommendations

Application available at: Application available at: http://ndms.fema.gov/forms.htmlhttp://ndms.fema.gov/forms.html

Centers for Disease Control Centers for Disease Control and Preventionand Prevention

Prepare and respond to public health Prepare and respond to public health emergenciesemergencies

Conduct investigations into health effects and Conduct investigations into health effects and medical consequencesmedical consequences

Assess health and medical needs of disaster Assess health and medical needs of disaster victimsvictims

Develop and maintain national systems for Develop and maintain national systems for acute environmental hazard surveillanceacute environmental hazard surveillance

Provide epidemiologic, laboratory and other Provide epidemiologic, laboratory and other scientific services to agencies involved in scientific services to agencies involved in disaster planning and responsedisaster planning and responsehttp://www.in.gov/isdh/bioterrorism/manual/image43.gif

Strategic National Strategic National Stockpile (SNS)Stockpile (SNS)

Previously known as National Previously known as National Pharmaceutical Stockpile (NPS) Pharmaceutical Stockpile (NPS) established in 1999established in 1999

Managed by CDCManaged by CDC National repository of antibiotics, chemical National repository of antibiotics, chemical

antidotes, antitoxins, life-support antidotes, antitoxins, life-support medications, medical/surgical suppliesmedications, medical/surgical supplies

Goal: Ensure rapid delivery within 12 hoursGoal: Ensure rapid delivery within 12 hours 3 main components3 main components

12 hour push packages12 hour push packages Enough drugs per packet to treat >100,000 peopleEnough drugs per packet to treat >100,000 people

Vendor-managed inventoryVendor-managed inventory CDC maintains supply of chemical antidotesCDC maintains supply of chemical antidotes

SNSSNS Can be requested by the state and shipment begin Can be requested by the state and shipment begin

within 12 hours pending federal government within 12 hours pending federal government approvalapproval

State responsible to provide manpower to State responsible to provide manpower to dissemble packaging and transport dissemble packaging and transport pharmaceuticalspharmaceuticals

Must factor in time to distributeMust factor in time to distribute Role of pharmacy personnelRole of pharmacy personnel

Ensure proper storage Ensure proper storage Provide recommendations for therapeutic alternativesProvide recommendations for therapeutic alternatives Patient screening and triagePatient screening and triage Dispensing of pharmaceuticalsDispensing of pharmaceuticals ImmunizationsImmunizations Patient counseling and compliancePatient counseling and compliance

May extend expiration dateMay extend expiration date

http://www.hhs.state.ne.us/images/BT/nps.jpg

ASHP Statement on the Role of ASHP Statement on the Role of Health-System Pharmacists in Health-System Pharmacists in

Emergency PreparednessEmergency Preparedness Pharmacists should play a key role in planning and Pharmacists should play a key role in planning and

execution ofexecution of Pharmaceutical distribution and controlPharmaceutical distribution and control Drug therapy management of patientsDrug therapy management of patients

Be involved in the followingBe involved in the following Development of guidelinesDevelopment of guidelines Selection of pharmaceuticals and supplies for national, Selection of pharmaceuticals and supplies for national,

regional and local emergency inventoriesregional and local emergency inventories Ensure proper packaging, storage, handling, labeling and Ensure proper packaging, storage, handling, labeling and

dispensing of emergency suppliesdispensing of emergency supplies Ensure proper deployment of emergency supply of Ensure proper deployment of emergency supply of

pharmaceuticalspharmaceuticals Ensure appropriate education and counselingEnsure appropriate education and counseling

Advise public health officials on appropriate Advise public health officials on appropriate messages to convey to the publicmessages to convey to the public

Collaborate with physicians in managing drug Collaborate with physicians in managing drug therapytherapy

Commitments made by Commitments made by ASHP ASHP

Maintain electronic communications Maintain electronic communications networknetwork

Disseminate prompt information to Disseminate prompt information to ASHP membersASHP members

Disseminate timely evidence-based Disseminate timely evidence-based information about pharmaceuticalsinformation about pharmaceuticals

Meet with government officials and Meet with government officials and others regarding involvement of health-others regarding involvement of health-system pharmacists in emergency system pharmacists in emergency preparedness and counterterrorismpreparedness and counterterrorism

Key Roles of a Pharmacist Key Roles of a Pharmacist in Bioterrorismin Bioterrorism

SurveillanceSurveillance InformationInformation Patient education and counselingPatient education and counseling Distribution of pharmaceuticals and Distribution of pharmaceuticals and

medical suppliesmedical supplies Administration of vaccinesAdministration of vaccines Evaluation/TriageEvaluation/Triage Community planning and Community planning and

preparationpreparation

SurveillanceSurveillance

Observe patients and their health Observe patients and their health needsneeds

Monitor and report any identified Monitor and report any identified increases in purchases of over-the-increases in purchases of over-the-counter products for fever, pain or counter products for fever, pain or diarrheadiarrhea

InformationInformation

Remain calm and provide Remain calm and provide reassurancereassurance

Be assertiveBe assertive Educate public, media and health Educate public, media and health

professionalsprofessionals Prevent irrational behaviorPrevent irrational behavior Obtain medication history and Obtain medication history and

allergiesallergies

Patient Education and Patient Education and CounselingCounseling

Ensure appropriate use and safetyEnsure appropriate use and safety Prevent toxicities and side effectsPrevent toxicities and side effects Enable identification of other Enable identification of other

medical and psychological medical and psychological conditionsconditions

Monitor for safety, efficacy and Monitor for safety, efficacy and adherenceadherence

Monitor for side effectsMonitor for side effects

Distribution of Distribution of Pharmaceutical and Pharmaceutical and

Medical SuppliesMedical Supplies Obtain extra pharmaceuticals from Obtain extra pharmaceuticals from

wholesalerswholesalers Keep medications organized and under Keep medications organized and under

close supervisionclose supervision Maintain security of controlled substancesMaintain security of controlled substances Package and label appropriatelyPackage and label appropriately Prepare drugs onsitePrepare drugs onsite Monitor usage of drugs and predict which Monitor usage of drugs and predict which

drugs need to be ordereddrugs need to be ordered

Administration of Administration of VaccinesVaccines

Role of pharmacist is moving from Role of pharmacist is moving from distributor of vaccines to administrator of distributor of vaccines to administrator of vaccinesvaccines

Pharmacists must be trained and educated Pharmacists must be trained and educated in the technique of providing immunizationsin the technique of providing immunizations

Growing number of pharmacists who are Growing number of pharmacists who are certified to immunizecertified to immunize

Target vaccines associated with Target vaccines associated with bioterrorism: bioterrorism: SmallpoxSmallpox AnthraxAnthrax

Evaluation and TriageEvaluation and Triage

Triaging disaster victimsTriaging disaster victims Trauma managementTrauma management Prevent communicable diseasesPrevent communicable diseases Assist in transporting patients to Assist in transporting patients to

shelters or homesshelters or homes

Community Planning and Community Planning and PreparationPreparation

Contact local and state public health and Contact local and state public health and emergency medical officials to become emergency medical officials to become part of emergency response teampart of emergency response team

Coordinate actions with state board of Coordinate actions with state board of pharmacypharmacy

Contact prescription drug benefit plans Contact prescription drug benefit plans regarding protocols for emergency re-fillsregarding protocols for emergency re-fills

Set up a handbook of contact informationSet up a handbook of contact information Wholesalers, distributors, manufacturers, Wholesalers, distributors, manufacturers,

communications companiescommunications companies

Community Planning and Community Planning and PreparationPreparation

Develop list of drugs, biologicals, Develop list of drugs, biologicals, supplies, nutritionals for emergency supplies, nutritionals for emergency sheltersshelters

Contact list of company representatives Contact list of company representatives to assist in obtaining drugs/suppliesto assist in obtaining drugs/supplies

Create a list of pharmacists you can call Create a list of pharmacists you can call upon for assistanceupon for assistance

Prepare an emergency kitPrepare an emergency kit Have bioterrorism resources readily Have bioterrorism resources readily

available (Internet, PDA)available (Internet, PDA)

Pharmacy Emergency Pharmacy Emergency Response Team (PERT)Response Team (PERT)

Trained to respond to chemical, biological, Trained to respond to chemical, biological, radiological, and nuclear agentsradiological, and nuclear agents

Identify a lead pharmacist and set responsibilities Identify a lead pharmacist and set responsibilities for team membersfor team members

Involvement of pharmacy director, administrative Involvement of pharmacy director, administrative support, clinical pharmacistssupport, clinical pharmacists

Establish collaboration and coordination of the Establish collaboration and coordination of the role pharmacy has in disaster managementrole pharmacy has in disaster management

Set procedures for emergency cart fillsSet procedures for emergency cart fills Resources are provided for efficient Resources are provided for efficient

communication and protectioncommunication and protection Provide staff educationProvide staff education Conduct drills to optimize functioning of the teamConduct drills to optimize functioning of the team

How to PrepareHow to Prepare Develop an extensive emergency planDevelop an extensive emergency plan Know federal and local disaster management Know federal and local disaster management

plansplans Enhance the link between pharmacy and first Enhance the link between pharmacy and first

responders, medical and mental health services, responders, medical and mental health services, public health officials, law enforcement officerspublic health officials, law enforcement officers Develop a local network of pharmacists, EMS, Develop a local network of pharmacists, EMS,

physiciansphysicians Regional poison control centerRegional poison control center State and local agenciesState and local agencies Local and state professional associationsLocal and state professional associations State emergency management groupsState emergency management groups

How to Prepare: Be How to Prepare: Be Educated and TrainedEducated and Trained

Become familiar with agents of Become familiar with agents of concern, their treatment, concern, their treatment, prophylaxis and epidemiologyprophylaxis and epidemiology

Take training classes in emergency Take training classes in emergency preparednesspreparedness

Learn first aid and become certified Learn first aid and become certified in cardiopulmonary resuscitation in cardiopulmonary resuscitation (CPR) and advanced cardiac life (CPR) and advanced cardiac life support (ACLS)support (ACLS)

How to Prepare: Get How to Prepare: Get InvolvedInvolved

Develop the followingDevelop the following Antibiotic selection guidelinesAntibiotic selection guidelines Dosing charts for pediatric patientsDosing charts for pediatric patients Counseling informationCounseling information Immunization guidelines (especially for high risk patients)Immunization guidelines (especially for high risk patients) Post exposure prophylaxis recommendations both Post exposure prophylaxis recommendations both

primary and secondary exposureprimary and secondary exposure Assist in writing pharmaceutical distribution plansAssist in writing pharmaceutical distribution plans Take part in development of guidelines or Take part in development of guidelines or

treatment algorithms in management of patients treatment algorithms in management of patients exposed to bioterrorismexposed to bioterrorism

Work with wholesalers to develop plans to obtain Work with wholesalers to develop plans to obtain emergency pharmaceuticalsemergency pharmaceuticals

How to Prepare: Get How to Prepare: Get InvolvedInvolved

Teach other pharmacists, nurses, and Teach other pharmacists, nurses, and medical professionalsmedical professionals

Become certified to administer vaccinesBecome certified to administer vaccines Develop programs for mass prophylaxis Develop programs for mass prophylaxis

focusing on issues of drug security, focusing on issues of drug security, triage of patients, and counselingtriage of patients, and counseling

Take part in practice drills or training Take part in practice drills or training exercisesexercises Federal government can send training, Federal government can send training,

education and demonstration (TED) education and demonstration (TED) packagespackages

ResourcesResources American Society of Health-System PharmacistsAmerican Society of Health-System Pharmacists

http://www.ashp.org/emergency/http://www.ashp.org/emergency/ American Pharmaceutical Association (APhA) Pharmacist American Pharmaceutical Association (APhA) Pharmacist

Response CenterResponse Center http://www.aphanet.org/pharmcare/responsecenter.htmhttp://www.aphanet.org/pharmcare/responsecenter.htm

American Medical AssociationAmerican Medical Association http://www.ama-assn.org/ama/pub/category/6206.htmlhttp://www.ama-assn.org/ama/pub/category/6206.html

Centers for Disease Control (Bioterrorism preparedness and Centers for Disease Control (Bioterrorism preparedness and response)response) www.bt.cdc.govwww.bt.cdc.gov

John Hopkins University for Civilian Biodefense StrategiesJohn Hopkins University for Civilian Biodefense Strategies http://www.upmc-biosecurity.org/http://www.upmc-biosecurity.org/

Federal Emergency Management AgencyFederal Emergency Management Agency http://www.fema.govhttp://www.fema.gov

U.S. Food and Drug AdministrationU.S. Food and Drug Administration http://www.fda.gov/oc/opacom/hottopics/bioterrorism.htmlhttp://www.fda.gov/oc/opacom/hottopics/bioterrorism.html

National Disaster Medical SystemNational Disaster Medical System http://www.oep-ndms.dhhs.gov/http://www.oep-ndms.dhhs.gov/

ConclusionConclusion

Pharmacists are identified as being Pharmacists are identified as being an active participant in the an active participant in the preparation and response to events preparation and response to events related to bioterrorismrelated to bioterrorism

Pharmacists need to be educated Pharmacists need to be educated and be actively involvedand be actively involved

Utilize the available resources Utilize the available resources Be available to volunteer assistanceBe available to volunteer assistance

ReferencesReferencesTerriff CM, Schwartz MD, Lomaestro BM. Bioterrorism: Pivotal Clinical Issues. Terriff CM, Schwartz MD, Lomaestro BM. Bioterrorism: Pivotal Clinical Issues.

Pharmacotherapy 2003;23(3):275-90.Pharmacotherapy 2003;23(3):275-90.American Society of Health-System Pharmacists. ASHP Statement on the Role of Health-American Society of Health-System Pharmacists. ASHP Statement on the Role of Health-

System Pharmacists in Counterterrorism. Am J Health-Syst Pharm 2002;59(3):282-3.System Pharmacists in Counterterrorism. Am J Health-Syst Pharm 2002;59(3):282-3.American Society of Health-System Pharmacists. Summary of the Executive Session on American Society of Health-System Pharmacists. Summary of the Executive Session on

Emergency Preparedness and the Pharmaceutical Supply Chain Am J Health-Syst Emergency Preparedness and the Pharmaceutical Supply Chain Am J Health-Syst Pharm 2002;59(3):247-53.Pharm 2002;59(3):247-53.

Teeter DS. Bioterrorism Preparedness: Answers for the Health-System Pharmacist Am J Teeter DS. Bioterrorism Preparedness: Answers for the Health-System Pharmacist Am J Health-Syst Pharm 2002;59(10):928-30.Health-Syst Pharm 2002;59(10):928-30.

Gaudette R, Schynitzer , George E, Briggs SM. Lessons Learned from the September 11th World Trade Center Disaster: Pharmacy Preparedness and Participation in an International Medical and Surgical Response Team. Pharmacotherapy 2002;22(3):271-81.

Schultz CH, Koenig KL, Noji EK. Disaster Preparedness. In: Marx JA, Hockberger RS, Schultz CH, Koenig KL, Noji EK. Disaster Preparedness. In: Marx JA, Hockberger RS, Walls RN, editors. Rosen’s Emergency Medicine Concepts and Clinical Practice. Walls RN, editors. Rosen’s Emergency Medicine Concepts and Clinical Practice. London: Mosby; 2002. p. 2631-45.London: Mosby; 2002. p. 2631-45.

Department of Homeland Security. National Response Plan; December 2004. Available Department of Homeland Security. National Response Plan; December 2004. Available from: from: http://www.dhs.gov/dhspublic/theme_home2.jsphttp://www.dhs.gov/dhspublic/theme_home2.jsp

Emergency Preparedness and Response. Centers for Disease Control and Prevention. Emergency Preparedness and Response. Centers for Disease Control and Prevention. Available from: Available from: http://www.bt.cdc.govhttp://www.bt.cdc.gov

Cohen V. Organization of a health-system pharmacy team to respond to episodes of Cohen V. Organization of a health-system pharmacy team to respond to episodes of terrorism. Am J Health-Syst Pharm 2003;60:1257-63.terrorism. Am J Health-Syst Pharm 2003;60:1257-63.

APhA Pharmacist Response Center. Available from: APhA Pharmacist Response Center. Available from: http://www.aphanet.org/pharmcare/responsecenter.htmhttp://www.aphanet.org/pharmcare/responsecenter.htm