U.S. Medical Countermeasure Development Since 2001: A Long Way Yet to Go

Pharmacists enhance national security through medical countermeasure program leadership

BACKGROUND

Chemical, biological, radiological, or nuclear threats and emerging infectious diseases are significant threats to public health and national security. U.S. Customs and Border Protection plays a vital role in safeguarding the nation's borders and protecting against all threats. Pharmacists, with their expertise in medication and public health, can play a crucial role in medical countermeasure (MCM) programs.

OBJECTIVES

The study aims to identify pharmacist-led quality improvements and explain expanded pharmacist roles through advancing a federal MCM program.

PRACTICE DESCRIPTION

U.S. Customs and Border Protection is the nation's largest law enforcement agency charged with protecting the American people and safeguarding the nation's borders.

PRACTICE INNOVATION

Program management for MCM transitioned to the Office of the Chief Medical Officer under pharmacist leadership, better aligning the program with the agency's health security mission.

EVALUATION METHODS

Pharmacists conducted a baseline program analysis then spearheaded 5 improvements over 1 year to fill identified gaps. Pharmacist-led improvements include development of a Standard Operating Procedure for accountability, SharePoint site development for inventory tracking/reporting, inventory analysis through SharePoint utilization, creation of a MCM channel in Microsoft Teams for information sharing, and establishment of a Point of Dispensing exercise schedule for readiness.

RESULTS

Pharmacist-led improvements resulted in Standard Operating Procedure recognition as best practice guidance by the Department of Homeland Security, improved inventory completion rates from 0% to 99%, initiation of 29 new MCM sites protecting 3,000 additional U.S. Customs and Border Protection workforce and persons in custody, inventory distribution to 55 sites protecting 35,000 additional personnel and persons in custody, enrollment of 247 members to the MCM channel in Microsoft Teams, improved Point of Dispensing exercise completion from 5% to 66%, and scheduled 90 Point of Dispensing exercises.

CONCLUSION

Pharmacists play a vital role in MCM program advancement and contribute to national security efforts against chemical, biological, radiological, or nuclear threats and emerging infectious diseases.

Prioritizing investments in rapid response vaccine technologies for emerging infections: A portfolio decision analysis

This study reports on the application of a Portfolio Decision Analysis (PDA) to support investment decisions of a non-profit funder of vaccine technology platform development for rapid response to emerging infections. A value framework was constructed via document reviews and stakeholder consultations. Probability of Success (PoS) data was obtained for 16 platform projects through expert assessments and stakeholder portfolio preferences via a Discrete Choice Experiment (DCE). The structure of preferences and the uncertainties in project PoS suggested a non-linear, stochastic value maximization problem. A simulation-optimization algorithm was employed, identifying optimal portfolios under different budget constraints. Stochastic dominance of the optimization solution was tested via mean-variance and mean-Gini statistics, and its robustness via rank probability analysis in a Monte Carlo simulation. Project PoS estimates were low and substantially overlapping. The DCE identified decreasing rates of return to investing in single platform types. Optimal portfolio solutions reflected this non-linearity of platform preferences along an efficiency frontier and diverged from a model simply ranking projects by PoS-to-Cost, despite significant revisions to project PoS estimates during the review process in relation to the conduct of the DCE. Large confidence intervals associated with optimization solutions suggested significant uncertainty in portfolio valuations. Mean-variance and Mean-Gini tests suggested optimal portfolios with higher expected values were also accompanied by higher risks of not achieving those values despite stochastic dominance of the optimal portfolio solution under the decision maker’s budget constraint. This portfolio was also the highest ranked portfolio in the simulation; though having only a 54% probability of being preferred to the second-ranked portfolio. The analysis illustrates how optimization modelling can help health R&D decision makers identify optimal portfolios in the face of significant decision uncertainty involving portfolio trade-offs. However, in light of such extreme uncertainty, further due diligence and ongoing updating of performance is needed on highly risky projects as well as data on decision makers’ portfolio risk attitude before PDA can conclude about optimal and robust solutions.

Confronting the threat of bioterrorism: realities, challenges, and defensive strategies

Global terrorism is a rapidly growing threat to world security, and increases the risk of bioterrorism. In this Review, we discuss the potential threat of bioterrorism, agents that could be exploited, and recent developments in technologies and policy for detecting and controlling epidemics that have been initiated intentionally. The local and international response to infectious disease epidemics, such as the severe acute respiratory syndrome and west African Ebola virus epidemic, revealed serious shortcomings which bioterrorists might exploit when intentionally initiating an epidemic. Development of new vaccines and antimicrobial therapies remains a priority, including the need to expedite clinical trials using new methodologies. Better means to protect health-care workers operating in dangerous environments are also needed, particularly in areas with poor infrastructure. New and improved approaches should be developed for surveillance, early detection, response, effective isolation of patients, control of the movement of potentially infected people, and risk communication. Access to dangerous pathogens should be appropriately regulated, without reducing progress in the development of countermeasures. We conclude that preparedness for intentional outbreaks has the important added value of strengthening preparedness for natural epidemics, and vice versa.

Managing public health data: mobile applications and mass vaccination campaigns

In response to data collection challenges during mass immunization events, Denver Public Health developed a mobile application to support efficient public health immunization and prophylaxis activities. The Handheld Automated Notification for Drugs and Immunizations (HANDI) system has been used since 2012 to capture influenza vaccination data during Denver Health's annual employee influenza campaign. HANDI has supported timely and efficient administration and reporting of influenza vaccinations through standardized data capture and database entry. HANDI's mobility allows employee work locations and schedules to be accommodated without the need for a paper-based data collection system and subsequent manual data entry after vaccination. HANDI offers a readily extensible model for mobile data collection to streamline vaccination documentation and reporting, while improving data quality and completeness.

Structural and immunochemical relatedness suggests a conserved pathogenicity motif for secondary cell wall polysaccharides in Bacillus anthracis and infection-associated Bacillus cereus

Bacillus anthracis (Ba) and human infection-associated Bacillus cereus (Bc) strains Bc G9241 and Bc 03BB87 have secondary cell wall polysaccharides (SCWPs) comprising an aminoglycosyl trisaccharide repeat: →4)-β-d-ManpNAc-(1→4)-β-d-GlcpNAc-(1→6)-α-d-GlcpNAc-(1→, substituted at GlcNAc residues with both α- and β-Galp. In Bc G9241 and Bc 03BB87, an additional α-Galp is attached to O-3 of ManNAc. Using NMR spectroscopy, mass spectrometry and immunochemical methods, we compared these structures to SCWPs from Bc biovar anthracis strains isolated from great apes displaying “anthrax-like” symptoms in Cameroon (Bc CA) and Côte d’Ivoire (Bc CI). The SCWPs of Bc CA/CI contained the identical HexNAc trisaccharide backbone and Gal modifications found in Ba, together with the α-Gal-(1→3) substitution observed previously at ManNAc residues only in Bc G9241/03BB87. Interestingly, the great ape derived strains displayed a unique α-Gal-(1→3)-α-Gal-(1→3) disaccharide substitution at some ManNAc residues, a modification not found in any previously examined Ba or Bc strain. Immuno-analysis with specific polyclonal anti-Ba SCWP antiserum demonstrated a reactivity hierarchy: high reactivity with SCWPs from Ba 7702 and Ba Sterne 34F2, and Bc G9241 and Bc 03BB87; intermediate reactivity with SCWPs from Bc CI/CA; and low reactivity with the SCWPs from structurally distinct Ba CDC684 (a unique strain producing an SCWP lacking all Gal substitutions) and non-infection-associated Bc ATCC10987 and Bc 14579 SCWPs. Ba-specific monoclonal antibody EAII-6G6-2-3 demonstrated a 10–20 fold reduced reactivity to Bc G9241 and Bc 03BB87 SCWPs compared to Ba 7702/34F2, and low/undetectable reactivity to SCWPs from Bc CI, Bc CA, Ba CDC684, and non-infection-associated Bc strains. Our data indicate that the HexNAc motif is conserved among infection-associated Ba and Bc isolates (regardless of human or great ape origin), and that the number, positions and structures of Gal substitutions confer unique antigenic properties. The conservation of this structural motif could open a new diagnostic route in detection of pathogenic Bc strains.

Development of drug-approval regulations for medical countermeasures against CBRN agents in Japan

To develop approval regulations for drugs against chemical, biological, radiological, or nuclear (CBRN) agents in Japan, and to help inform arguments about the development of anti-CBRN agents, we analyzed documentation describing approval processes and data for drugs against CBRN agents. Sixteen countermeasure products against 10 CBRN agents have been approved in Japan. Approval schemes were grouped into 3 categories: application for off-label uses, expedited review for antiterrorism measures, and expedited review. Ten drug applications were designated "priority reviews," and the median review time was 4.4 months. No application relied exclusively on clinical trials to expose patients to CBRN threats. Clinical experience with drugs in victims of unexpected exposure was not necessarily important for approval. The United States is the most advanced country in terms of developing medical countermeasure products against CBRN agents. Japan has similarities with the US in approved products and application packages, but there were 3 unapproved products or indications that were approved under the Animal Rule in the US. The Animal Rule might encourage development of a novel product by providing efficacy evaluation in animal studies. The US also has regulations that do not exist in Japan that authorize administration of an investigational drug outside a clinical trial for patients. Introduction of the Animal Rule and expanded access of investigational drugs could contribute to development and approvals of novel countermeasure products and improve an emergency response in a crisis in Japan.

Implications drawn from a military bioterror exercise in Israel

Orange Flame is an Israeli preparedness build-up project, conducted by the Ministry of Health, that is aimed at improving national readiness and preparedness for unusual biological events. The project is intended for both medical and nonmedical organizations, and, since 2011, the exercise has also included operational units outside the medical corps. This has provided valuable insights into the consequences of bioterror or naturally occurring outbreaks for operative functionality and for the unique medical, logistical, and administrative efforts required from the armed forces in such an event. The 2-day drill reported on here executed a notional scenario in which category A bioterror agents were dispersed, causing civil and military casualties. Military personnel observed and assessed the performances of all participating organizations and observed the employment of emergency protocols during the drill. Military sustainment and operative capabilities were significantly affected by the occurrence of an unusual biological event. Comprehensive actions to be executed during such a scenario included quarantining military bases, considering postponement of military operations, and transferring on-call missions to other bases. Logistic consequences included the need for manpower and equipment reinforcement, as well as food and water supplies in cases of suspected source contamination. The project unveiled many operational and logistic quandaries and exposed various potential effects of a bioterror attack in the military. Lessons learned were used to revise preevent national and military doctrine for unusual biological events.

Orthopoxvirus inhibitors that are active in animal models: an update from 2008 to 2012

Antiviral agents are being sought as countermeasures for the potential deliberate release of smallpox (variola) and monkeypox viruses, for the treatment of naturally acquired monkeypox virus infections, and as therapy for complications due to smallpox (live-attenuated vaccinia virus) vaccination or accidental infection after exposure to vaccinated persons. Reviews of the scientific literature spanning 1950-2008 have documented the progress made in developing small-animal models of poxvirus infection and identifying novel antiviral agents. Compounds of considerable interest include cidofovir, CMX001 and ST-246® (tecovirimat; SIGA Technologies, NY, USA). New inhibitors have been identified since 2008, most of which do not exhibit the kind of potency and selectivity required for drug development. Two promising agents include 4'-thioidoxuridine (a nucleoside analog) and mDEF201 (an adenovirus-vectored interferon). Compounds that have been effectively used in combination studies include vaccinia immune globulin, cidofovir, ST-246 and CMX001. In the future there may be an increase in experimental work using active compounds in combination.

Inhibitors of Bacillus anthracis edema factor

Edema factor (EF) is a calmodulin (CaM)-activated adenylyl cyclase (AC) toxin from Bacillus anthracis that contributes to anthrax pathogenesis. Anthrax is an important medical problem, but treatment of B. anthracis infections is still unsatisfying. Thus, selective EF inhibitors could be valuable drugs in the treatment of anthrax infection, most importantly shock. The catalytic site of EF, the EF/CaM interaction site and allosteric sites constitute potential drug targets. To this end, most efforts have been directed towards targeting the catalytic site. A major challenge in the field is to obtain compounds with high selectivity for AC toxins relative to mammalian membranous ACs (mACs). 3'-(N-methyl)anthraniloyl-2'-deoxyadenosine-5'-triphosphate is the most potent EF inhibitor known so far (Ki, 10nM), but selectivity relative to mACs needs to be improved (currently ~5-50-fold, depending on the specific mAC isoform considered). AC toxin inhibitors can be identified in virtual screening studies based on available EF crystal structures and examined in cellular test systems or at the level of purified toxin using classic radioisotopic or non-radioactive fluorescence assays. Binding of certain MANT-nucleotides to AC toxins elicits large direct fluorescence- or fluorescence resonance energy transfer signals upon interaction with CaM, and these signals can be used to identify toxin inhibitors in competition binding studies. Collectively, potent EF inhibitors are available, but before they can be used clinically, selectivity against mACs must be improved. However, several methodological approaches, complementing each other, are now available to direct the development of potent, selective, orally applicable and clinically useful EF inhibitors.

An interagency collaboration to facilitate development of filovirus medical countermeasures

The Filovirus Animal Non-Clinical Group (FANG) is a US interdepartmental and interagency group established to support and facilitate the advanced development of filovirus Medical Countermeasures (MCM), both vaccines and therapeutics. It is co-led by one representative from the Department of Defense (DoD), the first author, and one from the Department of Health and Human Services (HHS), the second author. The FANG membership includes operational level program staff and Subject Matter Experts (SME) from performing organizations as well as scientific staff and program managers from DoD and HHS funding and regulatory agencies. Focus areas include animal models, assays, reagents, product manufacture and characterization, and other interagency product development issues that will support Food and Drug Administration (FDA) licensure of safe and effective filovirus MCMs. The FANG continues to develop strategies to address broadly applicable and interagency product development challenges relevant to filovirus MCM development. This paper summarizes FANG structure and accomplishments and is meant to heighten community awareness of this government-led collaborative effort.