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标题：Use of Medical Countermeasures in Small-Scale Emergency Responses
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作者：Ijeoma A. Perry ; Rebecca S. Noe ; Amy Stewart 等
期刊名称：American journal of public health
印刷版ISSN：0090-0036
出版年度：2018
卷号：108
期号：Suppl 3
页码：S196-S201
DOI：10.2105/AJPH.2018.304491
语种：English
出版社：American Public Health Association
摘要：It is well documented that long-standing focus on public health emergency preparedness medical countermeasures (MCMs) distribution and mass dispensing capabilities for mitigation of bioterrorism incidents and a lack of real-world opportunities to test national preparedness for large-scale emergencies has hindered development of a body of evidence-based practices in the United States. To encourage jurisdictions seeking innovative opportunities for continuous improvement, we describe instances when the MCM capabilities were used to address smaller-scale, more-frequent public health emergencies such as disease outbreaks, natural disasters, or routine influenza vaccination. We argue that small-scale events represent a critical opportunity that state, local, tribal, and territorial entities can utilize for greater gains in MCM operational readiness than through exercises or planned reviews. By using and evaluating MCM capabilities during a real response, jurisdictions can advance preparedness science and support the translation of research into practice, thereby increasing their capacity to scale up for larger, rarer, higher-consequence emergencies. To respond effectively to a large-scale, rare, but high-consequence emergency such as an aerosolized anthrax attack, US communities will rely on the use of points of dispensing (PODs) as sites where the affected public can receive potentially lifesaving medical countermeasures (MCMs) deployed from the Centers for Disease Control and Prevention’s (CDC’s) Strategic National Stockpile. 1–4 For 15 years, CDC, through the Public Health Emergency Preparedness (PHEP) cooperative agreements and Cities Readiness Initiative funding stream, has provided significant support ($12.5 billion annually) for state and local public health departments to develop, test, and maintain MCM dispensing and administration plans and infrastructure. 1 A significant focus on funding bioterrorism preparedness followed the 2001 anthrax attacks. 3 As a consequence, efforts to develop the nation’s capability to dispense, manage, and distribute MCMs, as part of the PHEP cooperative agreements, have experienced fewer budget cuts than other preparedness activities. 1 While jurisdictions report increased levels of MCM distribution and dispensing capability, 1 studies have consistently found challenges in demonstration of MCM operational readiness despite the existence of developed plans. 1,5,6 With the rarity of large-scale bioterrorism emergencies and the rising frequency of natural disasters and international public health emergencies, 7 jurisdictions have progressively used exercises and rare, large-scale responses to infectious disease emergencies (e.g., H1N1 influenza pandemic response, Table 1 and Table A, available as a supplement to the online version of this article at http://www.ajph.org ) to validate their MCM plans and, thereby, cultivate awareness of gaps and potential solutions. 4,6,8,9,12–15 TABLE 1— The Impact and Lessons Learned Following the Use of Medical Countermeasures in Small-Scale Emergency Responses: United States, 2009–2017 Response and State (Year) Activity/Impact Lessons Learned Disaster response Yellowstone River oil spill—Montana (2015)^a During January 2015, a pipeline breach spilled 50 000 gallons of oil into the Yellowstone River. This river is the drinking water source for approximately 6000 residents of Dawson County, Montana. Access to multiple POD locations in the local MCM plan proved critical because the third option (community center with semi docks) had to be used. The water system was promptly shut down, and the LHD activated its MCM plan and a POD site. Within 1 day, a community center POD received pallets of water and dispensed drinking water to the residents. Public health employees and volunteers from the oil pipeline company provided the majority of the manpower and unloaded the first shipment of more than 15 pallets of water at the POD. The MCM plan incorrectly identified that volunteer management support would be available from national volunteer disaster response organization(s). A daily gallon of water per person and pet were distributed from the POD over 5 days. Most residents reported receiving their allocated amounts of water within 5–10 min of arriving at the POD. The rapid throughput was a result of changes made to initial POD traffic flow, the use of a donated forklift, and parking enforcement by Department of Transportation officers. Volunteers provided daily home delivery of bottled water to people with functional and access needs. Media management was problematic as the event was national news, and some news media organizations did not follow media protocols. Reporters entered unsafe areas where forklifts were in operation and increased the potential for injuries. A total of 80 000 gallons of water were distributed throughout the response and 40 000 gallons were stored at the end of the operation. The new engagement with the Department of Transportation filled an unexpected need for traffic management expertise (e.g., changed traffic flow) and enforcement (e.g., ability to ticket) to protect the safety of the pedestrians walking into the facility. Pandemic influenza outbreak response H1N1 response—Los Angeles, CA (2009–2010) 8,9 During the 2009 H1N1 influenza pandemic response, the LACDPH used 109 POD sites in Los Angeles to provide almost 200 000 doses of monovalent influenza A (H1N1)pdm09 (pH1N1) vaccine over 46 d. The inclusion of race/ethnicity in scheduled reports of vaccine utilization enabled identification of racial disparities among groups. A study of 101 POD vaccination events from 60 sites examined the effectiveness of POD operations. The average number of doses administered each hour at the 60 sites was 239 (range = 40–427) and an average of 247 persons (range = 7–1614) waited in line to be vaccinated. Countermessaging opposition to 2009 monovalent H1N1 vaccine within the African American community led to an ongoing need for extensive and varied approaches in communication and engagement activities. The 109 POD locations were located across Los Angeles County to facilitate access by diverse high-risk populations. Marked POD underutilization among the African American community persisted despite targeted community outreach (e.g., culturally appropriate health education materials, public service announcements, and use of faith-based organizations). The response emphasized a need to strengthen relationships with other health department programs that partner with minority communities. A total of 446 outreach events were implemented at a variety of locations including WIC offices, senior centers, and faith-based organizations. Other racial and ethnic groups were successfully vaccinated in the PODs. Coverage and representation of racial and ethnic minorities was accomplished by establishing POD sites within a high concentration of the target population. The response emphasized that the evident social and economic barriers should be addressed and from this experience LACDPH developed the Los Angeles County Community Disaster Resilience coalition ( http://www.laresilience.org/about.php ). POD throughput efficiency could have been improved by increasing the ratio of nonmedical staff to medical staff. This vaccination campaign was one of the largest POD-based efforts during the 2009–2010 H1N1 response. Non-influenza infectious disease outbreak response Largest botulism outbreak in 40 years in United States—Ohio (2015)^b In 2015, CDC’s DSNS deployed 50 doses of heptavalent botulinum antitoxin to Ohio in support of the largest botulism outbreak in 40 y in the United States. Increased awareness and compliance of state botulinum antitoxin protocol among health care providers and health department programs to ensure a coordinated and prompt request to CDC was needed. The antitoxin was delivered to the state within less than 10 h of the federal decision to deploy. The ODH received the shipment into its centralized vaccine storage location and divided the doses on the basis of requests from 7 different health care facilities in the Columbus area. The manufacturer’s quick-thaw instructions were not written in plain language, which led ODH to develop a supplemental “1-pager” that guided uptake of the correct procedure at the individual facilities. By midnight, the OSHP transported the initial botulinum antitoxin delivery from the state storage location to the health care facility that first alerted authorities about diagnosed patients. The opportunity to use OSHP in the future for transport of small quantities of time-sensitive life-saving medications from state warehouses to health care facilities was recognized. Of 29 people hospitalized at various facilities, 25 (86%) received botulinum antitoxin and 11 (38%) were intubated. After a week, 18 (62%) were discharged. It was determined that better communication with health care facilities is needed regarding storage and handling of the product on site. For instance, some facilities refroze botulinum antitoxin, which damaged some of it. The DSNS demonstrated its ability to rapidly deploy a large amount of botulinum antitoxin and transport this lifesaving MCM directly to a state receiving location. The state MCM distribution plans facilitated the pre-positioning of OSHP units and the opening of a vaccine warehouse that offered access to cold-storage repackaging and shipping supplies. These capabilities ensured the rapid (< 2 h) botulinum antitoxin processing and shipment to the medical center with critical patients. An LHD managed the transport of the other 6 requests by using nonemergency vehicles that were effective during this ongoing event. Opioid epidemic response Statewide distribution of naloxone—North Carolina (2017)^c In 2017, North Carolina’s PHP&R supported the DMH’s efforts to rapidly and effectively distribute nearly 40 000 units of naloxone (worth $3 million) over a 2-week period in October. The state’s PHP&R successfully used a component of its MCM plan by using their inventory software to provide necessary paperwork for the ad hoc distribution. Access to naloxone is a focus area of the North Carolina Opioid Action Plan. The product arrived at a state warehouse and the state’s PHP&R staff quickly used CDC’s Inventory Management and Tracking System software to generate chain-of-custody forms and packing slips. Accurate and timely release of product was coordinated with more than 70 partner agencies and organizations that came from across the state to pick up their allotment for their communities. The state’s MCM receiving and dispensing capability was not fully leveraged for this event because of 3 key factors: (1) a lack of awareness of the capability of PHP&R across the state health department, (2) time constraints placed on the DMH to distribute the product, and (3) competing priorities. It is possible that North Carolina will purchase more naloxone in the future and lessons learned from this distribution will allow for better coordination and communication and the ability to incorporate a future distribution into a statewide exercise to help strengthen this capability. Open in a separate window Note. CDC = Centers for Disease Control and Prevention; DMH = Division of Mental Health; DSNS = Division of Strategic National Stockpile; LACDPH = Los Angeles County Department of Public Health; LHD = local health department; MCM = medical countermeasures; ODH = Ohio Department of Health; OSHP = Ohio State Highway Patrol; PHP&R = Public Health Preparedness and Response; POD = point of dispensing; WIC = Special Supplemental Nutrition Program for Women, Infants, and Children. Table 1 is an abridged version of Table A, which presents a wider range of response activities and corresponding lessons learned and is available as a supplement to the online version of this article at www.ajph.org . ^aActivities/impacts and lessons learned from the Yellowstone River oil spill were provided by J. Fladager (e-mail communication, December 12, 2017). For more information, see the CDC Public Health Preparedness 2016 Snapshot . 3 ^bActivities/impacts and lessons learned from the largest botulism outbreak in 40 years in United States—Ohio were provided by T. McBride (e-mail communication, December 5, 2017). For more information, see McCarty et al. 10 ^cActivities/impacts and lessons learned from the statewide distribution of naloxone—North Carolina were provided by A. Williford (e-mail communication, December 4, 2017). For more information, see North Carolina Office of the Governor. 11 It is noteworthy that limited evidence in the literature suggests that some jurisdictions are capitalizing on the use of the MCM capabilities to respond to more frequent smaller-scale responses. 2,10,11,16,–17 Specifically, using MCM capabilities in real-world responses operationalizes the MCM plan, which can (1) improve the response, (2) reveal gaps in the plan that are not apparent in exercises, and (3) promote evidence-based practices. To illustrate these points, and demonstrate the range of innovative responses, we identified examples through personal communications to CDC and a targeted search for evaluations of real-world responses using PODs within the published literature, which we present in table and narrative form. The use of MCM capabilities in a routine event—an annual vaccination campaign—and an emergent response are presented as case studies to demonstrate two disparate types of events that are addressed with MCM capabilities.