Pharmaceuticals and Medical Equipment in Disasters

Most disasters create a predictable pattern of public health consequences, though the pattern varies according to the type of disaster. The types of disasters that may be expected and the potential risks that those disasters pose to the community should be outlined in the threat assessment resulting from the Hazard Vulnerability Analysis (HVA) for the local area conducted as a routine part of disaster planning (see Chapter 22 for further information on community-based HVAs). Epidemiologic and surveillance information is critical for determining current and predicted casualties and the amounts and specific types of medical supplies or equipment required. In addition to natural or technological disasters, the threat of domestic and international terrorism involving weapons of mass destruction (WMD) has become an increasing public health concern in the United States and abroad.

Because local resources will not always be sufficient for certain unlikely events such as WMD attacks, or for large-scale disaster response, additional resources can be made available through effective planning with suppliers and local and regional emergency response partners, as well as through agreements with and assistance from regional, state, and federal response organizations.

Equipment and supplies essential to the response capacity of a community can be categorized as follows: direction and control, communications, mass care, and health and medical supplies. Equipment and supplies for health and medical care may be divided into two broad categories. The first category includes the drugs, medical equipment, and supplies necessary for direct patient care. This category also includes provisions for care of routine chronic and acute medical conditions in the local populace in addition to the medical and health needs created by the disaster.

Because pharmacies and medical care clinics may be destroyed, have no power, or lack staff during a disaster, health planners should expect that patients will seek medical care for chronic conditions in acute care hospitals or in any available medical relief setting. If persons with chronic diseases who are medication dependent are unable to access their medications, they may no longer be simply evacuees or survivors of the event, but instead become patients requiring acute medical care. For example, the diabetic patient whose blood sugar is normally under good control, if deprived of his medications, may rapidly decompensate and suffer problems related to high blood sugar.

The second category includes the logistical and occupational health supplies used to support emergency workers and facilities. Some examples include portable shelters such as tents, portable water containers, patient stretchers, and personal protective equipment (PPE). The emergency manager must also plan to support uninvited volunteers.

The initial HVA should identify and inventory existing resources, equipment, and supplies essential to health and disaster management. This inventory will help the manager determine what additional supplies are needed, identify storage areas safe from both damage and pilferage, and ensure that perishable stocks do not exceed safe expiration dates. Appropriate management includes inventory of assets and distribution of this inventory to officers authorized to distribute the assets during time of need. Inventory logs should include potential bulk resupply sources and authorization codes, specialized equipment sources, and alternative sources for fuel, oxygen, and other expendable resources. Since transportation routes may be affected by any disaster, experienced emergency managers may include in pre-event planning alternative sources for all items. For example, supplies for southern Illinois usually come from St. Louis, but during the 1993 Midwestern floods, bridges across the Mississippi River were closed for more than 300 miles, so bulk supplies could be procured more quickly from Chicago.

Determining the quantities of medical supplies and pharmaceuticals needed during the initial disaster will depend on several factors including, but not limited to, the specific threat or disaster, availability of medical assets within the community, extent of disruption of the medical and health systems, number of potential and actual patients, clinical treatment or prophylaxis protocols, damage to roads and other transport modalities, damage to communication infrastructure, and time to the recovery phase of the disaster response. Attempts have been made to quantify pharmaceutical stockpiling or evaluate preparedness of emergency departments for a terrorist event involving a chemical nerve agent with 50 to 500 casualties. As noted later in this chapter, similar planning can and should occur for natural disasters such as tornados, hurricanes, earthquakes, and ice storms.

In addition to planning for specific threats, the emergency manager should contact the local public health authorities to ascertain the local prevalence of chronic diseases, such as hypertension, diabetes, and chronic obstructive pulmonary disease (COPD). This information can be used to augment supplies of anticipated necessary medicines for shelters and emergency clinics. The need for medications such as antiseizure medications, antihypertensives, tetanus immunizations, and antibiotics, for instance, can be estimated from local incidence rates provided by public health authorities as well as the expected illnesses and injuries from the disaster.

Although the federal government may provide assistance including medical assets and equipment, the local area should not expect that this assistance will arrive until at least 24 hours and perhaps up to 72 hours after a formal request from the state government(s) through the President. International aid often does not arrive for 72 hours or more. International requests for field hospitals should be made to the World Health Organization (WHO)/Pan American Health Organization (PAHO).

More and more such plans include planning for vulnerable populations in the disaster area. In the past, inadequate preparation for these vulnerable populations has led to catastrophic consequences and increased death tolls. Regardless of the type of disaster, the planner must recognize that current health problems will persist and may be markedly exacerbated by the ongoing disaster. Such vulnerable populations are listed in Table 57-1 .

Table 57-1

Health Care Populations to Plan For

Population	Needs
Victims of the disaster	Needs vary by type of disaster as injuries/illness caused by disaster may range from minor to lethal.
Vulnerable populations	Needs will vary by type of disaster and by vulnerability. Generally includes current hospital patients.
Rescue and health care workers	Rehabilitation, water, food, shelter, immunizations. Some may become victims of the disaster or aftermath.
General population	May include those with chronic illness who are not otherwise “vulnerable.” Some may become victims of the disaster or aftermath.
Evacuees/displaced persons	May include vulnerable populations. May include those with chronic illness who are not otherwise “vulnerable.” Some may become victims of the disaster or aftermath.

Water, food, shelter, and effective sewage disposal will be needed for everyone in the affected area. Although provision of such essentials is not often considered as part of the medical response, one only has to look at the Haiti earthquake to note the medical results from their lack.

Provision of critical medical needs is the province of the resource logistics manager. Effective resource logistics management requires several basic actions:

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Determining specific resources required for each group and the amounts required in each area affected by the disaster
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Procuring appropriate amounts of resources prior to an event
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Monitoring expiration dates and rotating stock as needed
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Developing systems to procure additional resources when needed through agreements with suppliers and response partners
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Preparing to receive potentially large amounts of unrequested medical assets
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Having mechanisms to monitor inventory and track resource use and identify potential shortages before they occur
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Identifying a means to transport and distribute resources
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Identifying locations for dispensing pharmaceuticals or other medical assets
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Developing a system for dispensing the medical assets

Historical perspective

The Homeland Security Act of 2002 and Homeland Security Presidential Directive (HSPD)-5 required the creation of the National Response Framework (NRF), which superseded both the Federal Response Plan and the National Response Plan. The NRF is a guide to how the nation conducts all hazards responses. It is built upon scalable, flexible, and adaptable coordinating structures that align key roles and responsibilities across the nation, linking all levels of government, nongovernmental organizations, and the private sector. It identifies specific authorities and best practices for managing incidents from the serious but purely local to large-scale terrorist attacks or catastrophic natural disasters defined under the Robert T. Stafford Disaster Relief and Emergency Act as events that result in extraordinary levels of casualties, damage, and disruption affecting the population or environment of a community.

In 1999 Congress charged the Department of Health and Human Services (HHS) and the Centers for Disease Control and Prevention (CDC) with the establishment of the National Pharmaceutical Stockpile (NPS). The mission was to provide large quantities of essential medical material to states and communities during an emergency within 12 hours of the federal decision to deploy. After the attacks in 2001, the Department of Homeland Security briefly assumed control of the stockpile and changed the name to the Strategic National Stockpile (SNS). The Department of Homeland Security gave the SNS back to the Department of Health and Human Services and the CDC. The CDC received funding under an Anti-Bioterrorism Initiative to develop the SNS into a program to assist states and communities respond to public health emergencies, primarily those resulting from chemical, biologic, and radiologic terrorist attacks. The resulting SNS program is part of the NRF and ensures the availability of medicines, antidotes, medical supplies, vaccines, and medical equipment necessary for states and communities to counter the effects of biologic pathogens, chemical agents, radiologic events, and explosive devices.

The SNS program is designed to deliver medical assets to the site of a biologic or chemical national emergency within 12 hours of the federal decision to deploy medical assets. (Under the Stafford Act, state authorities must request federal assistance before it is delivered.) Medical assets available through the SNS program include antibiotics, chemical nerve agent antidotes, intravenous fluids and administration supplies, bandages, burn ointments, analgesics, antiemetics, sedatives, antiviral medications, antitoxins, and vaccines. The SNS program includes “push packages” (prepackaged assortments of these pharmaceuticals) and medical supplies that may be needed for general resupply during a disaster. The push packages do not contain drugs and equipment for general primary care problems such as hypertension or diabetes.

Current practice

Terrorism

There are multiple sources for clinical recommendations with regard to the treatment of casualties from biologic, chemical, or radiologic weapons. Recommendations regarding PPE have been hampered by limited regulatory guidance and lack of focused research on use of PPE in health care facilities. However, the current consensus appears to support the use of Level C PPE (i.e., splash suits, gloves, boots, air-purifying respirators) in most health care settings. Hospitals and health emergency planners should maintain stockpiles of appropriate PPE and be prepared to decontaminate and care for persons in their community in response to threats identified in their HVA.

As noted, the SNS program’s formulary is directed at biologic, chemical, radiologic, and explosive weapons. A 12-hour or longer response time for delivery of chemical agent antidotes is not optimal for the initial care of casualties. In addition, many hospitals carry only limited stocks of chemical nerve agent antidotes. These antidotes have variable shelf lives; replacing them is costly and may impact a community’s ability to respond. Therefore, the SNS program has executed a nationwide forward deployment of chemical nerve agent antidotes under its CHEMPACK project. Through this project, emergency medical services and hospitals will have access to chemical nerve agent antidotes for immediate use during an event. Even with this forward deployment of chemical nerve agent antidotes, it is doubtful that antidotes will be immediately available after a terrorist release of a nerve agent.

Certain biologic threat agents and public health disasters such as epidemics may require prophylaxis for persons responding to the event. Stockpiles provided through the SNS can reduce the time to prophylaxis for first responders and provide a sense of security for their welfare. Local medical stockpiling may be one option for treatments that must be given within minutes to hours after an event, often much sooner than federal assistance can arrive. Communities with specific technological risks, such as chemical storage depots or nuclear power plants, may consider stockpiling specific antidotes or treatments as part of their disaster plan.

Appropriate training for the use of all stockpiled equipment should be considered. Medical personnel in charge of stockpiles used to address biologic, chemical, or radiologic agents will need to regularly review their formularies for inclusion of improved vaccines and newer treatment modalities, and for changes to a drug’s approval status by the Food and Drug Administration (FDA).

Natural Disasters

The SNS is not designed to handle natural disasters such as hurricanes, earthquakes, tornados, and floods. Similar rapidly deployable stockpiles (or subsets of stockpiles) could be designed to meet the needs incurred by natural disasters likely to strike in a particular area; however, no such current rapidly deployable assets are currently configured.

The public health consequences of natural disasters should also guide emergency planners in assessing the pharmaceutical and medical equipment needs of their communities. Several medical equipment and supply lists exist and can provide examples from which emergency planners may select and begin developing an inventory appropriate for their populations based on the threat analysis.

When planning for extremely large, or prolonged events, an available international resource is WHO’s Emergency Health Kit. This publication offers a standard list of essential emergency health supplies that are widely accepted internationally, calculated to meet the needs of 10,000 persons for 3 months. The kit inventory is divided into 10 identical units that each treat 1000 persons, so it is scalable to need. It is designed to meet the needs of a refugee camp and the priorities associated with austere conditions in developing nations. In addition, WHO has published and developed an essential drug list of pharmaceuticals that should be available at any given time in appropriate amounts and formulations. The WHO essential drug list has been adopted by numerous international agencies that supply pharmaceuticals within their health care programs and is being used to evaluate the appropriateness of drug donations.

A recommended list of medical supplies for health care personnel responding to victims of earthquakes has been developed by emergency medicine faculty at the University of California, Irvine Medical Center. The listed supplies can fit into backpacks kept by specially trained medical personnel in the trunks of their cars at all times.

Centralized or decentralized stockpiles of medical supplies and equipment may be considered as an option for disaster preparedness. Stockpiling medical assets for natural disasters is an expensive option. Not only are the costs high for initial purchase of pharmaceuticals and equipment, but the budget must include the cost of replacement for expired or worn-out items. Equipment must be maintained and quality assurance provided. Equipment may also need to be replaced as newer models become available. There may be significant logistical costs associated with maintenance, storage, and transportation of the inventory. The SNS can supply some equipment needs for disasters due to natural hazards, but only to a limited extent.

Beyond the financial concerns of stockpiling medical supplies and assets, there are multiple logistical and clinical considerations for states, communities, or hospitals. First, storage locations must be determined. Pharmaceuticals should be stored in a secure and temperature-controlled environment. An inventory system should be incorporated that allows up-to-date information on available products and expiration dates, controls access to restricted pharmaceuticals such as narcotics, and tracks distributed products or assets. Any centralized storage system of medical assets must be combined with an efficient and secure distribution system. Preference should be given to medical assets that have longer expiration dates and require no specialized storage needs or ancillary supplies.

Clinical considerations include assessing products for duplicity of use. Products that can be used to respond to multiple agents or events can reduce the number of pharmaceuticals purchased. For example, doxycycline is approved by the FDA to treat multiple biologic agents including, anthrax, tularemia, and plague. Decisions regarding which formulations of products to stockpile should consider special populations such as children or those persons who cannot swallow pills. Appropriate sizes of medical equipment for children should be considered.

Emergency managers may opt to arrange for anticipated necessary supplies from bulk drug/medical supply houses to be delivered on a “just-in-time” basis after a specific disaster. Examination of needs for similar disasters can guide these arrangements. These supply houses can also ensure that soon-to-expire drugs are sent to hospitals for rapid real-time use rather than discarding them months later from a stockpile. Coordination with commercial pharmacy chains may also enhance recovery efforts as these large chains have the ability to provide response packs tailored to local population needs for chronic illness maintenance drugs or provide prescription information for evacuees who use their services.

Management of Pharmaceutical Donations

After an event, multiple individuals, corporations, and governments may wish to contribute by sending possibly needed medications to the disaster area. Publicity following major disasters may lead to inappropriate donations that can create multiple secondary problems at the scene of the disaster. Recurrent problems with these donations and some possible solutions are identified in Box 57-1 .

Box 57-1

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