CorrectCare

Meds in Pandemic Flu Planning: The Missing Puzzle Piece
By Scott Savage, DO, CCHP, KtB

When preparing the statewide pandemic influenza plan, the Ohio corrections department was able to use many of the typical sources of information for medical movement, triage, disease containment and communications. But one area left us with no significant literature: medication lists.

Many of the usual sources did not apply to corrections. For example, the military treats only generally healthy persons; their deployment lists exclude populations seen in correctional settings, such as patients with diabetes, hepatitis C and HIV. Likewise, lists used by missionary medical providers don’t apply because of the limited availability of many medications in Third World countries and the presence of diseases that are rare in the United States: malaria, yellow fever and cholera are just a few.

So we developed our own list, selecting medications to prevent and treat only immediate life-threatening conditions for short periods (about one week). They were selected for their ability to treat a wide variety of potentially serious conditions in the event of a massive pandemic. For example, diphenhydramine (Benadryl) was chosen because it has anxiolytic, antiemetic, antidyskinesia, antipruritic and sedative effects.

The list is generic: Some patients will require specific formulary and nonformulary medications to prevent and treat uncommon or unusually severe conditions that are not reflected here. For example, medications used as adjuvants in cancer chemotherapy are not listed because of the highly individualized nature of treatment. It is critical to develop lists of medications for specific patients who have these types of conditions and to ensure that adequate supplies are maintained for them.

Also, medicines found on typical crash carts are not listed because many facilities depend on local ambulance services to provide this care. Facilities large enough to have resuscitation teams will need to consider how they want maintain them.

Medications on this list were not selected on a cost-effective basis for routine use and should not be considered as routine stock. When available, both oral and injectable forms will be useful.

Admittedly, difficult and subjective trade-offs were made. If Tylenol is on the list, is it necessary to have Motrin, as well? Given the two broad-spectrum and admittedly expensive antibiotics listed, should azithromycin also be included? Is there enough incidence of intoxication to warrant having activated charcoal on the list?

Facing Realities
In the end, the objective was to use a small number of versatile medicines for several reasons. First, the physical reality is that because of increased demand and loss of personnel, the medical services organization will be on the verge of chaos. It is not enough to have a nice list of medications. The medications must be obtained, stored, processed, accounted for and distributed. The shorter the list, the more likely facilities will be able to actually deliver medications to the patient in times of extreme stress.

Second, the political reality is that it will be easier for correctional administrators to add medications to the list than to explain to the myriad groups of citizens, patients and governmental oversight committees why they are not including them.

Finally, the financial reality is that if the list is too extensive, the correctional system may be forced to do nothing at all rather than try to pick and choose options.

As well as choosing what medicines to add or substitute, each organization must determine medication stocking levels. Many variables come into consideration; budget is obvious, but even storage arrangements, inmate populations, time to resupply and availability of staff during a crisis must be considered. Importantly, if more than seven days of crisis is anticipated, HIV-related antiviral medications must be on this list, and  discussion with a hepatologist about hepatitis C treatment medications should be considered, as well.

Of course, it is expected that most, if not all, medications prescribed to patients will be given until it is impossible or dangerous to do so as determined by the organization director. This list is only a small part of a larger plan for dealing with catastrophic pandemic influenza outbreak. The medications listed below should be the highest priority to stock in case of such an event.

— About the author:  Scott Savage, DO, CCHP, KtB, was assistant medical director for the Ohio Department of Rehabilitation and Correction when he wrote this. A Fellow of the American College of Emergency Medicine, he has extensive military training in disaster medicine and planning.

[This article first appeared in the Fall 2006 issue of CorrectCare.]