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The confirmed cases of anthrax may still be isolated, but the growing panic across the country is not. Pharmacists need to prepare now to meet any possible bioterrorism situation that may arise, advocates say. (To learn about potential threats and their treatments, see chart below.)
"The key message is to be prepared," says Mitchel Rothholz, RPh, vice president for professional practice of the American Pharmaceutical Association in Washington, DC.
"Have a plan in place. If you don’t have stock [of antibiotics that treat biological agents] on hand, you are going to have to answer questions from patients."
One of the best ways to prepare is to become part of a larger response network, says Joe Deffenbaugh, MPH, professional practice associate at the American Society of Health-System Pharmacists (ASHP) in Bethesda, MD. "Pharmacists should work through their hospital safety officers to find out if they are in one of the 120 metropolitan medical response systems identified by the Public Health Service." The total metropolitan medical response systems will be increasing to 200 in the next two years. Hospitals that are not in major metropolitan areas should find out what is going on in their state, he says.
Pharmacists should get involved in the planning activities around pharmaceutical availability and distribution, he says. "That would include what products to have on hand and how those products would be on hand among all of the health care facilities within a particular geographic area."
Otherwise, pharmacists are left to face the million-dollar question on their own: What stock do you need on hand? "That’s the hardest question to answer, not knowing what kind of hit hospitals are going to take," Rothholz says.
The question of having enough drugs to get you through the initial stages is going to be a new discussion topic around the pharmacy and therapeutics tables of each institution, he says. "There will be some hierarchy of decisions depending upon the agent — what is the treatment of choice? In terms of anthrax, you can use the Cipro [ciprofloxacin] or doxycycline. You have some variety. In some cases, depending upon the strain, penicillin would work."
In a chemical situation, pharmacists would need atropine, he says. "Do hospitals have enough on hand? Is there a shortage? Potentially there could be. There will be a lot of discussion about this."
Rothholz also suggests working with the emergency response system. Some hospitals are allowing the emergency response system to rotate or maintain their stock, he says. Most hospitals would struggle with ordering additional doses and having it sit on their shelves. "No system can afford to have it sit and not be productive inventory."
Jumping the gun and stockpiling antibiotics is one of the worst things pharmacists can do, says Deffenbaugh. "They shouldn’t go out and try to buy a lot of ciprofloxacin or any of the drugs that have been recommended for the treatment of any of these biological agents. That would be premature and is not going to be useful — and would contribute to a potential shortage of those items."
Working out a mechanism to obtain supplies in case of a run on the drug treatments is another primary recommendation, Rothholz says. "One of the fears now is that people stockpiling the drugs will cause a disproportionate distribution of the necessary antibiotics and other medications."
Smaller hospitals have more of a challenge in getting enough stock in case of a problem, he says. "They don’t carry a larger inventory, and they are farther away from some distribution centers than hospitals in the city. They also have less opportunity for sharing among institutions depending upon what’s happening."
Pharmacists need to remember that between community pharmacies and hospitals, there is a distribution of supply that can be tapped into, he explains. "Unless the roads are all torn up, the National Guard may be used to move [drugs] from one pharmacy to another."
Pharmacists also have to consider access points if they need to get someone treated, Rothholz adds. "The community pharmacies, the parking lot, and the hospitals can all be tapped into as delivery sites."
One problem threatening the antibiotic supply is the increasing number of regular citizens who are afraid of getting anthrax and who are obtaining prescriptions for antibiotics from their physicians. This might result in other health problems down the road, Rothholz says.
"The biggest concern we have right now in the whole health care system is, if patients start taking Cipro or other antibiotics, will this exacerbate the situation of antibiotic resistance? We may not see patients dying of anthrax, but they may die of other infectious diseases that we don’t have antibiotics to treat."
In the community setting, pharmacists should take special care with the patients who have obtained a prescription for ciprofloxacin because they are worried about a bioterrorist attack, says Deffenbaugh. "Pharmacists should use [their interaction] as an opportunity to educate patients about the inappropriateness of doing that. But that’s hard because everyone is panicking."
Pharmacists also need to ensure that they are educated about the biological agents so they are on alert in their own facilities. With situations involving agents such as anthrax, people don’t suddenly start dropping, Rothholz says. "They are going to come into pharmacies with symptoms on the fly and try to medicate themselves. Your stockpeople may notice they are stocking a lot more of anti-diarrheal or cough-and-cold products."
That could be a sign, he says. "That’s where your staff can really come into play."
The infectious disease personnel in your facility are good sources for education about these biological agents. Pharmacists should work with them to develop guidelines for what they would do in the event of an attack. Pharmacists also should obtain the Working Group on Civilian Biodefense articles that deal with the five most likely biological agents: anthrax, smallpox, plague, botulinum toxin, and tularemia, says Deffenbaugh. (The articles are available free on the Journal of the American Medical Association web site — jama.ama-assn.org/ — and also are referenced on the ASHP site.)
The Center for Civilian Biodefense Studies at John’s Hopkins University offers fact sheets on those five biological entities, too. (This web site can be found at www.hopkins-biodefense.org.) Pharmacists should periodically check the Centers for Disease Control and Prevention’s web site at www.cdc.gov/ for updated information on the biological agents and treatment, as well.
(Editor’s note: Another resource for bioterrorism preparedness is ASHP’s Emergency Preparedness — Counterterrorism Resource Center. This information can be accessed at www.ashp.org/public/proad/emergency/em_prep.html.)
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