Public Health Emergencies: Unpacking Medical Countermeasures Management for Preparedness and Response Introduction and Contents of the Volume

Imagine this fictional scenario: an airline passenger returning to the United States after working in a foreign country suddenly develops chills, headache, muscle pains, and a high fever in flight. Seeking immediate medical attention after landing, the index patient discovers she has a novel strain of influenza. Meanwhile, the virus is transmitted in flight by the recirculated air on-board, exposure to coughing, touching contaminated bathroom door knobs, and at least 180 other passengers. The disease continues to spread as the other infected passengers encounter more people after disembarking.

In this fictional account, we identify the initiation of a mass medical emergency that could be mitigated with appropriate distribution and dispensing of medical countermeasures (MCMs). Variations on this theme are in countless books, movies, and television shows. If thousands of people were sick at one time, overwhelming local resources, where would medicine to treat people come from? How would thousands of antiviral medications or immunization doses be transported, distributed, and dispensed to areas of need? How would the supply chain be secured, managed, and stored to ensure MCM safety, efficacy, and quality?

Mass-medical emergencies require coordinated preparation, practices, and strategies to dispense a wide range of pharmaceuticals and other medical supplies rapidly to the public residing in an impacted area. A critical component of the nation’s biodefense is the Strategic National Stockpile, the nation’s supply of potentially life-saving pharmaceuticals and medical supplies for use in a public health emergency severe enough to deplete local supplies. The volume herein provides a glimpse of public health preparedness requirements to ensure that MCMs are available for immediate deployment when the public requires protection.^1,2 Included here are 14 articles in the form of briefs, commentaries, a public health practice summary, analytic essay, and a series of content focused editorials to highlight past, present, and future considerations for MCM preparedness programs, response, and evaluation.

BRIEFS

In a research brief, Pagaoa et al. (p. S221) present results of data received by the Centers for Disease Control and Prevention (CDC) from national facility setup exercises, which focus on readying points of dispensing locations for a mass medical emergency. Setup times from an annual national exercise conducted in 2012 to 2016 are described for more than 400 local jurisdictions from 50 states and eight US territories. This brief informs the readers on future target times for points of dispensing setup activities and performance.

Cathcart et al. (p. S212) describe just-in-time training, developed by CDC and designed for rapid response implementation, and summarize experiences from two scenarios: during the 2016–2017 national Zika response and adaptation for points of dispensing essential training.

COMMENTARIES

Iskander et al. (p. S179) offer a history of the Rapid Deployment Force teams of the United States Public Health Service, which comprise a multidisciplinary team of officers including nurses, pharmacists, physicians, health service and other specialty health officers to support MCM responses during large-scale emergencies.

Bhavsar et al. (p. S183) present an overview of the Strategic National Stockpile assets available for deployment during an emergency. They offer a comprehensive description of regulatory, controlled substance, and cold chain management considerations that state, local, tribal, and territorial health departments should plan for and implement during a large-scale MCM emergency response.

Meyer et al. (p. S188) review the mass vaccination efforts for seasonal influenza in Taiwan, which both mitigate the effects of seasonal influenza and serve as a functional exercise for mass vaccination operations during a pandemic. The authors identify lessons that are applicable to emergency MCM dispensing in the United States.

Perry et al. (p. S196) highlight real-world application of MCM responses in several local jurisdictions while providing details about instances in Oklahoma (as an influenza vaccination campaign) and Rhode Island (as a response to a meningitis outbreak). The authors maintain that in addition to annual exercises, smaller-scale responses can effectively validate state and local public health emergency MCM operational capabilities, and evaluation of these events can further characterize outstanding issues to be prioritized and resolved.

PUBLIC HEALTH PRACTICE

Romero et al. (p. S227) detail the innovative Zika Contraception Access Network (Z-CAN), established to mediate the spread of the disease in Puerto Rico in 2016 to 2017. Contraception was an MCM used to reduce adverse Zika-related reproductive outcomes during the outbreak. Z-CAN established a chain of custody for receipt and distribution of contraceptive products in compliance with federal and territorial regulations, and Z-CAN physicians provided client-centered contraceptive counseling and services at no cost for at-risk women.

ANALYTIC ESSAY

Koonin and Patel (p. S215) detail key components CDC identified for administering MCMs in the event of a pandemic influenza outbreak. Considerations for regulatory considerations, dispensing, distribution, antiviral supply, and treatment effectiveness are discussed.

EDITORIALS

Measer et al. (p. S224) bring the US Food and Drug Administration (FDA) perspective about monitoring the use, safety, and effectiveness of MCMs in real-world, emergency settings—important issues especially when the MCM is an investigational new drug (off-label) or authorized for emergency use. The FDA is primarily responsible for protecting and promoting public health through the control and supervision of MCMs such as prescription and over-the-counter pharmaceutical drugs, vaccines, biopharmaceuticals, and medical devices.

Wyte-Lake et al. (p. S207) discuss how the Veterans Health Administration’s Home Based Primary Care (HBPC) program, which serves 53 000 older veterans, is increasing focus on disaster preparedness through implementation of the HBPC Patient Assessment Tool. The tool, a simple comprehensive checklist, sensitizes providers and patients to consider strategies in advance of an emergency for health protection. Planning for emergencies is particularly critical for persons with medical device dependencies (types of MCMs like oxygen, ventilators, respirators, etc.), and decisions are readily available to share with first responders during an emergency.

Ugarte et al. (p. S209) discuss the Pan American Health Organization initiative to enhance preparedness and response capabilities in the Latin American and Caribbean (LAC) region. The Emergency Medical Teams Initiative focuses on quality and accountability standards for deploying foreign field hospitals (a type of MCM); pandemic influenza and Zika response in the LAC region are also highlighted.

Horn and Kirsch (p. S202), international aide physicians, emphasize the importance of preparedness planning for noncommunicable, chronic disease populations. They offer solutions for improved response outcomes for this population including personal preparedness plans (that include medication lists and histories) and increasing stockpiles to include common pharmaceuticals (insulin, oxygen, etc.) and durable medical equipment.

Lehnert et al. (p. S194) describe four critical mass vaccination components the CDC recommend jurisdictions exercise and test in preparation for a severe influenza pandemic, requiring 2 doses of influenza vaccine with or without a separate adjuvant within a specific time interval.

Broderick et al. (p. S204) describe the US military’s effort to implement a large-scale vaccination program to protect active duty personnel against hepatitis A and B virus; this effort is noteworthy, given the likelihood for deployments in response to large-scale events or to conflict areas where hepatitis is endemic.

The articles presented within this supplement represent a small fraction of the topic areas spanning the varied and complex components of an MCM response. The state of the nation’s biodefense continues to evolve and shine new light on emerging issues and challenges related to supporting an MCM response. A successful MCM mission relies on seamless coordination of a multitude of stakeholders across local, state, tribal, territorial, and federal entities, agencies, organizations, public and private partners, and individuals. Continued training, assessment, and evaluation are critical to ensure timely, and appropriate quality care following mass emergencies that rely on MCMs to foster optimal health outcomes for all people.