1. Regional Pharmaceutical Resources Colleen Terriff, PharmD, BCPS (AQ-ID), MPH (soon) Clinical Associate Professor Washington State University College of Pharmacy Deaconess Hospital and Rockwood Health Systems November 21, 2013

2. History of Involvement 1999 hoax anthrax letter Y2K preparation for hospitals Poster at Midyear and AJHP publication MMRS Spokane City/County Pharmaceutical Coordinator (2000- present) Sept 11, 2001 Participation in variety of exercises: – Mass vaccination – Mass dispensing – Mass casualty

3. Pharmaceutical Coordinator CDC CHEMPACK med exchanges Assist with public health Stockpiling: – Decisions: location, medications, ancillary supplies – Distribution – Dosing and preparation information – Inventory – Destruction

4. Pharmaceutical Resources MMRS Stockpiles CHEMPACKS SNS Antiviral Cache VA Cache HRSA Employee Cache Hospital Inventory for SRHD Community Pharmacy Inventory as needed

5. Bioterrorism Planning AgentProphylaxisTreatmentPlan AnthraxAntibiotics Local and SNS BotulinumObserveAntitoxin Supportive care SNS PlagueAntibiotics Local and SNS SmallpoxVaccineInvest. Drugs Supportive care SNS TularemiaAntibiotics Local and SNS VHFInvest. Drugs Supportive care SNS

6. Local Bioterrorism Pharmaceutical Plan (MMRS) Agents – Levaquin IV/PO, doxycycline IV/PO, gentamicin IV Others – dosing syringes, sterile water for injection Considerations – pediatrics, pregnancy, elderly, immunocompromised – first-responders and healthcare professionals – prophylaxis vs. treatment

7. Chemical Terrorism Planning AgentTreatmentPlan Nerve Agents2-PAM, atropine, diazepam Local (CHEMPACK) and SNS VesicantsSupportive care (BAL for Lewisite) SNS- BAL Industrial Chemicals Supportive care (Cyanide antidotes) Local and SNS Riot AgentsSupportive careLocal and SNS

8. Local Chemical Terrorism Pharmaceutical Plan (MMRS) Nerve agent antidotes: – 2004: MARK-1 and diazepam autoinjectors with “sprinklings” of 2- PAM vials, diazepam carpujects ALS transport (AMR and Medstar) and non-transport (fire) – 2009: Duodotes Cyanide antidotes (hydroxocobalamin) – fire chief rigs – Expired: AMR

9. CHEMPACK Program Nerve agent antidotes – antidotes more readily available – improve local response time – treat thousands of patients (including peds) Federally owned cache – decrease cost to local areas: initial and replacement – Shelf-Life Extension Program (SLEP)

10. Shelf-Life Extension Program Previously- military SNS in conjunction with the FDA may extend shelf-life of meds (expiration date) Strict criteria: – storage and security Meds from CHEMPACK: – regardless of dating on vials/packages…. – ensured potency!! Just implemented for Tamiflu susp.

11. CHEMPACK Distribution Eastern Washington Hospital: – Deaconess – Holy Family – Sacred Heart – Valley EMS: – AMR (x2) – Valley Hospital – Colville – Pullman

12. Strategic National Stockpile Program CDC/Federal Government assistance Stockpile (4 components): – 12 hour push package antibiotics (IV and PO) and antidotes fluids, bandages, IV supplies, supportive care meds – Vendor Managed Inventory- drug or equip.-specific – Vaccine and Antitoxin – CHEMPACK program- pilot: NY, SD, WA Additional resources: personnel, $$

13. Antivirals Spring 2009 CDC released 25% of SNS antivirals DOH received antivirals and then distributed to sites identified by local HD Local: – Hospitals – Retail/chain with expanded access Issues: – storage (physical) – short expiration of suspension – different packaging

14. Antiviral Issues Continued… Locals now own stockpile Who is the “gatekeeper” of access? Need to use up local supply (in pharmacies) first, then can utilize SNS Ancillary supplies…

15. VA Stockpile Large facilities Small facilities: – Spokane Mass casualty Color coded Includes supportive care meds 2008 Directive

16. HRSA Employee Cache Ciprofloxacin Doxycycline For employees and families and hospital- based EMS providers Maintained by area hospitals

17. Deaconess Stockpiles 1.MMRS- ill patients (i.e. IV meds) ED provider can access 2.MMRS- POD – SRHD or Spokane EOM- to be sent to POD 3.CHEMPACK plus expired meds 4.Antiviral SNS cache 5.Employee cache Antibiotics and antivirals HRSA grants

18. Hospital Pharmacy Inventory Deaconess and Shriners Holy Family and Deer Park Sacred Heart Valley VA Antibiotics, chemical exposure treatment, antivirals Estimation SRHD listed resource

19. Community Pharmacy Inventory Enroll help of: – WSU College of Pharmacy Drug Information Center – Spokane Pharmacy Association Limited meds Dispensing to community

20. MOU’s with Pharmacy State-wide initiative community pharmacies: – Chains – Independents SRHD with WSU COP: – Mass dispensing – Mass vaccination

21. Medication Destruction Partnering with law enforcement (SPD) Coordinating stockpile destruction with other incineration needs for LE Mainly MMRS chemical terrorism meds

22. Moving Forward MMRS defunct CHEMPACK program will continue until ? Local stockpiles expired Keep expired meds until funding changes