The Use of MedKits to Augment Rapid Distribution of Antibiotics after an Anthrax Attack
By Mary Beth Hansen and Luciana Borio, M.D., March 14, 2008
A Complex and Daunting Challenge
Following an anthrax attack, many lives could be saved by timely distribution of antibiotics to exposed populations.1 Today, all states have plans to receive, store, and distribute antibiotics from the Strategic National Stockpile (SNS).2 However, because of the enormous challenges that attend rapid mass distribution of antibiotics, few localities, if any, are prepared to manage such an undertaking within the required timeframe during an emergency.3 At the “Workshop on Medical Countermeasures Dispensing” held at the Institute of Medicine (IOM) on March 3-4, 2008, Dr. Gerald Parker, Principal Deputy Assistant Secretary of Preparedness and Response at the U.S. Department of Health and Human Services (HHS), remarked that if the dispensation of antibiotics to an exposed population cannot be completed within 48 hours of the decision to do so, the opportunity to save lives will be missed. He further stated that if the antibiotics stored in the SNS are not distributed quickly, they will be like the flooded school buses during Hurricane Katrina.
Multiple Strategies Needed
There are two primary strategies currently in play: points of dispensing, or PODs, and direct distribution of antibiotics, usually by the United States Postal Service. Use of PODs is commonly referred to as a “pull” mechanism because people will be pulled to the antibiotics; in contrast, direct distribution is referred to as a “push” mechanism, because antibiotics are pushed to people. While each of these solutions holds some promise, neither will suffice to provide prophylaxis in the necessary time frame during a disaster.
However, it is increasingly recognized that a multi-faceted solution holds the best promise for meeting the demands of this complex problem. Attention has turned recently to a third strategy—that of prepositioning a limited amount of antibiotics in advance of any event by providing antibiotic kits to households, private businesses, or a more narrow group of first responders. The kits would be for use during an emergency under the direction of public health authorities. Prepositioning would enable rapid access to antibiotics if needed, and would buy time for public health authorities to ramp up their distribution activities.
CDC Reports Results of First Study of this Strategy
There have been many doubts about the feasibility of prepositioning, though. Of the many questions to be answered, a fundamental one is whether households will stockpile the antibiotic kits and use them only when directed, or will make use of antibiotics on hand when a household member becomes ill during a non-emergency. The Centers for Disease Control and Prevention (CDC), in partnership with the Missouri Department of Health and Senior Services, sought to answer this question through the Emergency MedKits Evaluation Study. Linda Neff of the CDC reported the results at the IOM meeting on March 3, 2008.
In the study, selected households in the St. Louis area received a MedKit prototype: a blister pack with a five-day supply of ciprofloxacin, doxycycline, or both, and detailed instructions. Participants belonged to one of three cohorts: 1) clients and some employees of a community health clinic; 2) corporations; and 3) first responders. The goals of the study were to assess the ability of households to maintain the MedKits as directed and reserve them for use only when directed during an emergency; to explore psychosocial factors that may affect participant behavior related to proper storage and use of the MedKit; and to assess the acceptability of the household MedKit prototype.
97% (3,946 out of 4,076) of all study respondents returned the MedKits upon completion of the study, and 99% of the returned MedKits were intact (i.e. no pills missing).
130 (3%) of households did not return the MedKits; 125 of these could not find their MedKits, and 5 refused to return them. Only 4 households, all in the clinic cohort, reported having used their MedKits.
94% or more in each cohort indicated they would like to have a MedKit in their home.
Approximately 85% indicated they would be willing to pay for a MedKit, for a price, on average, of about $23 per person
These results support the viability of the MedKit strategy to augment antibiotic distribution during an emergency. They suggest that, with clear instructions, the majority of households will not misuse antibiotic kits distributed for emergency use. However, there are many questions still to be addressed.
For example, if the federal government moves to implement a MedKit program, will it cover the general population or limit coverage to first responders? If the most daunting task is to distribute antibiotics to an exposed population in a short time frame, it is important to cover the general population. In the past, public health authorities strongly advised against individual stockpiling of antibiotics.4,5 The federal government will have to work with professional medical societies to explain the rationale and get support for such a program.
How will the program be paid for? Even if limited in scope, such a program would be expensive because it requires paying for both initial distribution of MedKits and periodic replacement for an indefinite period of time. In a recent interview, Dr. William Raub, Science Advisor to HHS Secretary Leavitt, stated that, “household stockpiling of pharmaceuticals for use during public health emergencies could be an important modality of personal preparedness if we can develop products and approaches that are affordable; easy to obtain, maintain, and use; and consistent with medical and public health principles.” He also stated that HHS will seek “to encourage commercialization of antibiotic MedKits.” This suggests an expectation that households ultimately may have to foot the bill for MedKits, an approach consistent with Secretary Leavitt’s oft-stated commitment to encouraging personal responsibility.
There are other regulatory and logistical challenges that need to be addressed as well. These include, but are not limited to: management of state regulatory and legal variations for dispensing medications, dispensation of the remainder of the necessary 60-day course of antibiotics, management of shelf-life and drug expiration, and tracking of MedKits.
If the many thorny issues surrounding this strategy can be addressed adequately, MedKits may prove to be an innovative and useful tool. They would provide for immediate access to life-saving antibiotics, while also decreasing surge demand at local PODs and increasing the efficiency of other distribution methods. As one part of a multi-layered solution to the problem of rapid mass distribution of antibiotics, this form of citizen stockpiling may be important component. At the moment, though, it is too soon to tell whether the federal government will pursue such a program, and whether it would seek to cover the general population, or just first responders.
Michelle Cantu, MPH, and Brooke Courtney, JD, MPH, contributed to this report.
- Bravata DM, Zaric GS, Holty JE, et al. Reducing mortality from anthrax bioterrorism: strategies for stockpiling and dispensing medical and pharmaceutical supplies. Biosecur Bioterror 2006;4:244-62. http://www.liebertonline.com/doi/abs/10.1089/bsp.2006.4.244. Accessed March 14, 2008.
- Centers for Disease Control and Prevention. Public Health Preparedness: Mobilizing State by State. A CDC Report on the Public Health Emergency Preparedness Cooperative Agreement. February 20, 2008. http://emergency.cdc.gov/
publications/feb08phprep/. Accessed March 14, 2008.
- Trust for America’s Health. Ready or Not? Protecting the Public's Health from Disease, Disasters, and Bioterrorism, 2007. December 18, 2007. http://healthyamericans.org/reports/bioterror07/BioTerrorReport2007.pdf. Accessed March 14, 2008.
- New York City Department of Health and Mental Hygiene. Public Health Emergency Preparedness Bioterrorism Q & A. http://www.nyc.gov/html/doh/html/cd/wtc8.shtml. Accessed March 14, 2008.
- U.S. Medicine Institute for Health Studies. Surge Capacity: Is It Time to Move Beyond ‘Just-in-Time’? Washington, DC. June 1, 2002. http://www.usminstitute.org/pdf/surge_summary.pdf. Accessed March 14, 2008.