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Questions raised as localities stockpile anthrax antidotes


Fire Lt. Randall Owens keeps one in the locker at his Rockville station and another in the master bathroom of his Frederick County home. His are two of the 7,000 "bio-packs" of anthrax antidotes given to 3,500 Montgomery County firefighters and police officers.

First-responders are given two supplies of doxycycline or ciprofloxacin -- antibiotics used to treat anthrax infections --in clear pouches the size of fanny packs, to keep with them at home and work.

In a push to control their own fate, Montgomery County, Baltimore City and other jurisdictions around the country are spending federal homeland security grant money to create stockpiles of antidotes that duplicate drugs readily available through the six-year-old Strategic National Stockpile program, which has cost more than $2 billion to assemble.

The jurisdictions want to ensure that they have drugs on hand to treat emergency personnel -- and in some cases, their families -- on a moment's notice so that fire, police or health department employees can respond to a bioterrorism event.

"It makes a difference knowing that you can take the medicine immediately and not put your family at risk through exposure," said Owens, 48, a grandfather and 28-year firefighting veteran.

'Kind of nuts'

But William Stanhope of the Institute for Bio-Security at the Saint Louis University School of Public Health, is highly critical of the practice.

"The idea is kind of nuts," he said. "It presumes it is going to be an anthrax attack, and it presumes that we will know in an instant. ... A bioterrorist attack will not be white powder floating out of the sky. It will not be obvious. It will be covert."

In Baltimore City and Montgomery County alone, the cost for the drugs has totaled about $100,000 since the terrorist and anthrax attacks of 2001.

Von Roebuck, a spokesman for the Centers for Disease Control and Prevention in Atlanta, said that Montgomery County was among the first --perhaps the first -- jurisdiction to stockpile the antidotes into bio-packs. Roebuck said other governments around the country are bolstering the supplies of bioterrorism antidotes in hospitals, police stations and firehouses. For reasons of security, he declined to name the cities and counties.

Nor would he comment on the advisability of duplicating drugs in the national stockpile, which costs $397 million a year to maintain. The CDC keeps storehouses of antidotes in more than a dozen secret locations throughout the nation, including the Washington suburban area. Between 2002 and 2005, the stockpile increased its capacity of anthrax antidotes from 12 million to 60 million.

Baltimore Health Commissioner Dr. Peter L. Beilenson said the city has no plans "to just start throwing cipro out" to people and rushing into a bioterrorist event without analyzing the situation carefully.

"I'm a doctor. My first concern is to do no harm," he said. "We're just trying to be proactive and do the right thing with this [homeland security] money in a very smart, targeted way."

Although each pill costs about 6 cents -- and a fully stocked bio-pack is less than $7 -- the drugs expire and must be replaced every three years. Ciprofloxacin was the drug of choice during the anthrax attacks of 2001, but some people who take it suffer allergic reactions. Doxycycline is a widely used alternative.

In Montgomery County, which was the scene of some of the 2001 anthrax attacks, the cost has resulted in a recurring expense of $35,000 every three years.

The county used money from a 2002 Byrne grant -- a federal law-enforcement fund -- to buy its first supply of antidotes. County workers then assembled the bio-packs and handed them out. That batch of drugs will expire in November.

This year, the county is using money from a homeland security grant. Montgomery County homeland security director Gordon Aoyagi said he expects to pay for the drugs in the future with federal grants.

"As long as there remains a threat I would think the [federal] money would be available," he said.

Montgomery County officials bought their first drug supply in the fall of 2002, several months after the idea was hatched at a terrorism preparedness seminar in St. Michaels. During a brainstorming session, someone mentioned the "go packs" of supplies given to U.S. soldiers, and the bio-pack initiative grew from that, said Montgomery County bioterrorism coordinator Kathy Wood.

Since then, Wood and others have given bio-pack presentations at the CDC and fielded phone calls from public safety officials in Seattle, Boston and elsewhere, Wood said.

She said Montgomery County decided it was important for emergency personnel to have antidotes at their fingertips during a bioterrorist event instead of having to rush to a hospital or the health department to receive the medicine.

"That would mean taking firefighters and police off the street at a time when you need them there the most," she said. "It is a matter of time. Time is our enemy with this. ... Of all the things we've done [for homeland security], I believe this is one of the best.'

Stanhope said giving first-responders antidotes that defend against a single bioterrorist agent such as anthrax is likely to give them a false sense of security. "There's a good chance it won't be anthrax," he said.

In theory, drugs from the national stockpile are supposed to be dispatched and arrive anywhere in the nation within 12 hours. In the first test of the stockpile program, medical supplies and drugs were en route to New York City and Arlington, Va., by the early afternoon of Sept. 11, 2001.

However, Maryland officials say it can take up to 48 hours for antidotes such as doxycycline and ciprofloxacin to reach the general public.

"There is a difference between getting several trailer-loads of drugs to a central location in a state and then unpacking trailers and boxes and dividing the drugs into county sizes and dispersing them to the public," said Dr. Diane Matuszak, director of community health administration for the state Department of Health and Mental Hygiene. "You would want the [antidotes] in the hands of every citizen within 48 hours."

For that to occur, first-responders must act. In surveys taken by the Baltimore City Health Department, emergency personnel said fear for the safety of their families would be a deterrent to responding immediately to a biological attack, Beilenson said.

Because first-responders from the health department would be asked to set up clinics in advance of the arriving Strategic National Stockpile, Baltimore bought 5,475 bottles of doxycycline or ciprofloxacin last year for police, firefighters and public health employees. The total cost was $32,850.

Enough medicine was bought so that first-responders and their families would be temporarily immunized against anthrax. Beilenson called the purchase "dirt cheap" for the peace of mind it provides.

"You cannot wait to set up clinics," Beilenson said. "You shouldn't even wait four hours."

Montgomery County gave first-responder families letters written on county stationery that could be taken to personal physicians. The letters explain that the families could be exposed to anthrax because their spouse or parent is an emergency responder. Some have received prescriptions written in advance by their physicians; others have standing prescriptions, Aoyagi said.

If the firefighter or police officer is at work when a bioterrorism emergency occurs, the family is allowed to use the bio-pack stored at home if a physician has approved its use.

"They are aware that they can't just pop a pill in the mouth of a child. They need to work through their physician," Aoyagi said. "But we knew if we didn't take care of the families, we might not have a good turnout" in the event of bioterrorism.

Ethical quandary

Art Caplan, the director for the Center of Bioethics at the University of Pennsylvania, said he has no problem with the preferential dispensing of antidotes to those exposed as long as it's done logically. But the definition of "family member," he said, does not include everyone who might have close contact with a first-responder.

"What about your maid? What about your nanny? What about the newspaper delivery guy?" he said. "I think the issue boils down to who is likely to be exposed, not if you are a family member or not."

Beilenson said the decision to include families had nothing to do with fairness. It was about getting first-responders to the scene.

"I'm not saying it's correct or not correct, or ethical or not ethical. But let's be honest: The first-responder's biggest concern is that his wife is protected so that when he goes to work he doesn't have to worry about her getting ill and dying," Beilenson said. "Is it an ethical quandary? Sure."

Wood said the decision is ultimately the personal physician's, but that the county's letter did not include people beyond the immediate family.

"Where do you draw the line?' she said. 'It is a very evolving program, and as time goes on, we will have to grapple with different details of it."

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