Imagine the following scenario: a large, high profile sporting event is taking place at an open-air stadium with over 100,000 people in attendance. There are local, national, and international media outlets covering the event and tens of thousands of people have flocked into the area to take part in the excitement. Following the national anthem, there is a military fly-over, except this time it looks different. What looks like glitter, rains down from one of the planes, covering the entire stadium and surrounding areas. The crowd pays no attention as the glitter and confetti are assumed to be a part of the planned event. Through information gathered by law enforcement, it is found that aerosolized anthrax was intentionally mixed into the glitter and released over the whole area. All of the people in attendance have potentially been exposed to a highly pathogenic organism. What can be done in order to prevent disease and treat those who are already ill? Luckily, as a result of public health planning efforts in the United States since 2001, most jurisdictions have a plan in place to address these issues.
Planning the response to a biological incident of this scope requires a considerable amount of coordination. The initial response will include steps such as identifying the agent, determining the extent of spread, and coordinating with the media to notify the public. As these tasks are accomplished, priorities must then shift to prophylaxis for those who were potentially exposed and treatment for individuals who were exposed and are now displaying symptoms. In order to comprehend the multitude of issues involved in this type of response, it is essential to begin with an understanding of the basic concepts involved in this process.
Medical countermeasures are “products and interventions used to combat the effects of chemical, biological, radiological, or nuclear (CBRN) events.” (http://blog.bioethics.gov/2013/03/20/what-are-medical-countermeasures/) This includes pharmaceuticals such as antibiotics, antivirals, and vaccines, as well as equipment and supplies such as ventilators and personal protective equipment. For an aerosolized anthrax release like the one described, the primary prophylaxis for those exposed would be antibiotics. In addition to prophylaxis, treatment will be provided for those who were exposed and are now displaying symptoms. During the 2009-2010 H1N1 influenza pandemic, millions of doses of vaccine were distributed and administered to prevent disease while ventilators, personal protective equipment, and other medical supplies were provided to hospitals to help those who were already infected and to prevent further spread of disease. In the United States, guidance on the appropriate dispensing algorithms comes from several federal agencies including the Centers for Disease Control and Prevention (CDC) and the Food and Drug Administration (FDA). These guidelines define priority groups as well as any contraindications related to each medical countermeasure.
Once the dispensing algorithm and priority groups have been identified, the next step is to determine the appropriate method for dispensation. Mass prophylaxis planning focuses on the Point of Dispensing (POD) model, of which there are two types: Open PODs and Closed PODs. Open PODs, which are open to the general public, are usually at public facilities such as schools, fairgrounds, and government buildings. Everyone is welcome at an Open POD. In comparison, Closed PODs are used to dispense to certain members of a population through an agreement with their local health department. Examples of Closed PODs include large businesses, faith-based organizations, homeowner’s associations, and colleges/universities. Regardless of the type, each Closed POD receives medical countermeasures such as medicines or vaccines and provides them to their staff, students, or congregation as well as their families. While Open PODs are usually operated by the local health department and are open to all members of the population, Closed PODs are run by internal staff and only serve a specific part of the population. The primary goal of the Closed POD program is to reduce the amount of people that must go to Open PODs. If the exposed population is 1,000,000 people but 250,000 people are covered by Closed PODs, the Open POD only needs to serve 750,000 people instead of the full 1,000,000.
Dispensing medical countermeasures is a challenge and a very complicated undertaking that should not be coordinated alone. It is essential to develop relationships with community partners to determine what resources can be shared during this type of public health response. This approach is not only useful for mass prophylaxis campaigns, but also supports response to other types of incidents. For example, local public health agencies do not tend to have large warehouse space where receipt, staging, and storage of medical countermeasures can take place. However, community partners such as law enforcement, school districts, and local emergency management agencies might. Through strong partnerships identified gaps can be addressed and coordination between the agencies enhanced.
Medical countermeasure planning comprises numerous elements including developing appropriate guidance, opening and operating points of dispensing, and coordinating with community partners. When all of these elements come together, a successful medical countermeasure campaign can be accomplished.