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Mass Medical Prophylaxis

Intentional and natural disease outbreaks in the United States, such as the 2001 anthrax attacks and the 2003 influenza season, have focused increased attention on the ability of State and local public health authorities to provide affected individuals and communities with rapid, reliable access to prophylactic medications. In light of the substantial health risks posed by anthrax, influenza, and other bacteria, spores, toxins, or viruses, the U.S. Federal Government has called on all States to devise comprehensive mass prophylaxis plans to ensure that civilian populations have timely access to necessary antibiotics and/or vaccines in the event of future outbreaks.

The years following 2001 have seen a major expansion of Federal assets to assist local public health providers in the planning and execution of mass prophylaxis campaigns for bioterrorism and epidemic outbreak response, including development of the Strategic National Stockpile (SNS), improvement in public health laboratory capabilities, creation of a national Health Alert Network (HAN), and implementation of the Cities Readiness Initiative (CRI). However, none of these assets is intended to replace local first response capabilities or the need for comprehensive local plans for extended mass prophylaxis campaigns in the setting of a bioterrorist attack or natural disease outbreak.

State, county, and local health authorities have been charged with the development of these plans, with financial and technical support of the Department of Health and Human Services Office of Public Health Emergency Preparedness (OPHEP) as well as the Centers for Disease Control and Prevention (CDC).

Effective public health response to a bioterrorist attack or other disease outbreak hinges on the ability to recognize the outbreak, mobilize supplies of needed materials to affected populations in a timely manner, and provide ongoing medical care for affected individuals. There are 5 distinct components of this response:

1. Surveillance: Surveillance activities may range from use of passive systems for detecting specific pathogenic microbes in the environment to development of syndromic surveillance programs to mine existing emergency medicine, primary care, or pharmaceutical databases to rapidly identify unusual clusters of suspicious symptoms. Determination of appropriate trigger or action levels in these surveillance systems is an ongoing challenge for medical and public health personnel that will not be considered here.
2. Supply and Stockpiling: Response capacity to a large-scale bioterrorist attack may be limited by the ready availability of antibiotics and/or vaccines. For this reason, the Federal Government has created the Strategic National Stockpile (SNS), composed of a number of ready-to-deploy "Push Packs" containing medical supplies to treat thousands of patients affected by the highest-priority disease-causing agents (the CDC Category A agents), as well as pre-designated pharmaceutical supply caches and production arrangements that may be used for large-scale ongoing prophylaxis and/or vaccination campaigns (Vendor Managed Inventory, VMI). Some large municipalities and medical facilities across the country also have developed smaller stockpiles and secure supply chains for critical antibiotics and medical materiel for use in terrorism response.
3. Distribution: In the context of a mass prophylaxis response to bioterrorism, distribution refers to the logistics of transporting materiel such as antibiotics and vaccines from stockpile locations (e.g., the airhead where the SNS has been deposited) to dispensing centers where they are given to affected populations.
4. Dispensing: Dispensing operations are the final step in getting prophylactic medications and vaccines to affected populations. Dispensing center functions (described more fully in Section Two) include mass triage, medical evaluation of symptomatic individuals, pharmacotherapeutic consultation for drug or dosage adjustment if needed, and provision of antibiotics or vaccination. Additional functions may include data collection, patient briefings, mental health or pharmacist consultations, and emergency transportation for patients requiring medical care.
5. Followup: Followup may include monitoring patients for antibiotic effectiveness or vaccine immunoresponse, identifying patients who require dose modification, and arranging alternative treatment for patients who have adverse effects from the prophylactic treatment. As demonstrated after the 2001 anthrax prophylaxis campaigns, followup data gathering is also essential for determining compliance with recommended treatment regimens.