May 14, 2005
Cities Readiness Initiative expanding to 36 Cities: Mass distribution of (effective) antibiotics
On May 13 the US Department of Health and Human Services (HHS) announced that funding will be provided to expand the US Cities Readiness Initiative (CRI) from last year’s 21 pilot cities to include 15 more metropolitan areas in 15 US states (www.hhs.gov/news/press/2005pres/20050513.html).
The goal of the CRI is “to ensure the selected cities are prepared to provide oral medications during a public health emergency to 100 percent of their affected populations. This entails enhancing each city’s dispensing plans with trained staff and developing plans to augment with federal resources and alternative means of delivery”. One such option considered for alternative means of delivery has been by involvement of the US Postal Service (as mentioned in this Washington Newsletter posted July 26, 2004). A key requirement is that distribution to 100 percent of a metropolitan area be accomplished within 48 hours of the time of the decision to initiate antibiotic distribution.
An 8-page CRI Guidance for the coming year can be found on the CDC website (www.cdc.gov) by searching on the term “CRI”. The document resulting from this search that is dated May 13, 2005 contains “Appendix 3: Cities Readiness Initiative (CRI) Guidance,” which outlines thirteen (13) critical capacities ranging from medication dispensing sites to security, training, and public information planning. The frequently and understandably mentioned issue about providing prophylactic medications to the family members of some first responders is explicitly addressed in the section “Program Budget” on the last page (8/8).
The first page of this 8-page CRI guidance candidly outlines the stakes and one rationale for the CRI: “Of foremost concern is the ability to respond in a timely manner to a bioterrorism attack over a large geographic area with an agent such as Bacillus anthracis, the organism that causes anthrax. In this case, antibiotics must reach the population within 24-48 hours to have the greatest life-saving effect”.
As an Infectious Disease physician and a former interim Chief Medical Officer for the Washington, DC Department of Health I cannot overemphasize the absolutely critical need to determine the antibiotic susceptibility and resistance of a bacterial attack agent (e.g., anthrax, plague, tularemia, or others) before the CRI-mass distribution of antibiotics to one or more US metropolitan areas. For example, failure to be scientifically certain that the bacterial attack agent is susceptible to the antibiotics being distributed could impair antibiotic compliance by the exposed-infected population, delay implementation of the decision to mass distribute antibiotics by the high-level political and public health decision-makers, and jeopardize the confidence of the general population in these high-level officials and in their subsequent recommendations and directives.
At the same time, however, if the CRI timeline for distribution of antibiotics cannot be made until antibiotic susceptibility and resistance testing of bacterial cultures from symptomatic patients (rather than the initial environmental samples from rapid environmental detection systems such as BioWatch or Autonomous Environmental Detection Systems (APDS)) then very likely much larger numbers of casualties will result. At the present time, in the event of simultaneous or sequential aerosol attacks over one or more US cites or metropolitan areas, a high-level decision may very well have to be made about whether to initiate the CRI mass distribution of antibiotics before being 100% certain of the antibiotic susceptibility and resistance results. Advantages and disadvantages of deciding either way can be anticipated. Anything that can be done now to decrease the time necessary to determine what antibiotics the attack agent(s) can be effectively treated with will be priceless if and when the attack event occurs.
The pragmatic importance of rapidly testing for antibiotic-resistant anthrax is captured in Karen Hughes’ book “Ten Minutes from Normal” referring to the anthrax attack of 2001:
“We had received awful news the day before we left Washington: some of the anthrax that had been mailed to offices on Capitol Hill might be resistant to treatment with antibiotics…But on the helicopter, on the way to Air Force One to go to China, we got the call: “It is responding to antibiotics,” the president reported as he hung up the telephone, to smiles from Condi and me. ”That’s the best news you’ve had as president,” Condi said. (page 270).
Daniel R. Lucey, MD, MPH
Director, Center for Biologic Counterterrorism and Emerging Diseases
Washington Hospital Center
Adjunct Professor of Microbiology and immunology
Lecturer, Masters program in Biohazardous Agents and Emerging Diseases
Georgetown University School of Medicine