After Hurricane Matthew in 2016, pharmacy technicians prepare the mobile pharmacy to distribute medications to veterans in Tarboro, NC. Now, the mobile pharmacy units are being readied in the fight against COVID-19.
WASHINGTON—VA publicly released its plans to adapt its medical and pharmacy operations to meet the challenges of the coronavirus disease 2019, or COVID-19, pandemic in the United States late last month. The crisis response plan includes management and deployment of the All Hazards Emergency Cache of medications and mobile pharmacy units.
The emergency cache program was established in 2002 following the 9/11 terrorist attacks to ensure drugs and other medical supplies would be available for immediate deployment to veterans in the event of a local mass casualty event. The emergency cache was designed to bridge the gap between existing supplies and limited resupply and federal relief from the national Centers for Disease Control and Prevention Strategic National Stockpile, which was estimated to take one to two days or longer to arrive. None of the caches have been tapped for disaster response to date, although they have been used to cover shortages for patients in life-threatening situations.
MPUs include a 40-foot straight truck and three tractor trailers, which can roll to sites on an as-needed basis. They are staffed by volunteer pharmacists and pharmacy technicians recruited from the disaster emergency medical personnel system.
Local facilities can request mobile pharmacy units through their VISN, which will raise the request to the VA’s Office of Emergency Management. Once the request is validated and approved, the Office of Emergency Management will forward an assignment to EPS director to deploy a mobile unit to the requesting region.
First established by the VA in 2007, the mobile pharmacy units are positioned around the country to enable them to quickly reach a deployment site and begin functioning within hours as an outpatient pharmacy to fill medications for urgent and life-threatening conditions. The mobile pharmacy team will submit nonurgent prescriptions to the VA Consolidated Mail Outpatient Pharmacy to fill and mail to veterans.
Plan Assumptions
The COVID-19 response plan made four significant assumptions concerning pharmacy operations, some of which have already been proven well-founded. The plan assumed that information about the pandemic would remain “highly fluid,” pharmacies could face frequent and significant changes in operating conditions, demand for and shortages of pharmaceuticals would likely increase, and staffing would likely become more challenging due to sickness, quarantine, family illness and fear.
Certainly, the information available about COVID-19 continues to change as different rates of infection and death and clinical and demographic characteristics of those affected by the coronavirus appear to vary by country. Likewise, outbreaks in the U.S. have each followed their own timeline.
The operating conditions for VA pharmacies have also evolved rapidly as facilities cancel elective procedures and move to limit exposure of staff and patients to the virus. As a result, more pharmacy activity has been shifted to CMOP. The national VA website now says, “if you usually pick up your prescriptions in person, we encourage you to use our online prescription refill and tracking tool.”
A number of VISNs around the country have gone further. To limit exposure to COVID-19, the Boston VA Healthcare System said it was switching to an all mail-order system and would only honor emergent prescription needs for in-person pickup. The Milwaukee VA similarly noted it would only fill prescriptions for hospital discharge and emergency refills. The Oklahoma City VA Health Care System and others posted that they would no longer handle routine refills.
Drug Shortages
The third assumption also appears to be on target. Drug shortages have already emerged, with troubling implications for some veterans with chronic diseases.
Promising results from two small trials and a mention by President Donald Trump prompted a run on hydroxychloroquine, a drug primarily used to treat some types of malaria but also a widely prescribed treatment for discoid and systemic lupus erythematosus as well as rheumatoid arthritis. Shortages also have affected chloroquine, a related drug used for the same conditions.
Autoimmune disorders, including lupus and rheumatoid arthritis, are more common in veterans than in the general population. A study led by researchers at the San Francisco VA found that post-traumatic stress disorder doubled the relative risk of autoimmune disorders in veterans of the Iraq and Afghanistan conflicts.1 More than 20,000 active duty servicemembers and veterans receive treatment for lupus, according to the Lupus Foundation, and the CDC estimates that 25.6% of veterans have arthritis.
A French study with 36 patients suggested that treatment with hydroxychloroquine significantly reduced the viral load among patients infected with COVID-19 within six days and that adding azithromycin improved the drug’s efficacy.2 Further, a letter published last month in Nature journal Cell Research found that “remdesivir and chloroquine are highly effective in the control of 2019-nCoV infection” in lab-grown monkey cells.3 Trials with hydroxychloroquine, chloroquine and azithromycin are in process in New York and elsewhere, and the U.S. Food and Drug Administration granted the drugs emergency use authorization for coronavirus infections at the end of last month.
Scaling up production to meet the needs of existing patients and clinical trials may prove challenging. India blocked exports of the active pharmaceutical ingredient for hydroxychloroquine and the manufactured drug at the end of March, stunting efforts to increase production by a number of manufacturers.
The emergency cache program may not be able to fill the gap in critical drugs in a nationwide pandemic, given its mission to support localized mass casualty events. The emergency cache program had stockpiled $44 million worth of drugs and medical supplies at 141 VA medical facilities, according to a February 2018 report by the VA’s Office of the Inspector General. Ninety-one of the caches could meet the needs of 2,000 casualties in a disaster; 50 could meet the needs of 1,000 veterans in such a situation.
The IG’s report found “VHA has not been effectively managing its Emergency Cache Program and VHA officials gave no assurances the cache is ready to mobilize in the event of an emergency. VHA risks not having the drugs necessary to meet the emergency needs it might be facing because its emergency cache inventories carry expired, missing, or excess drugs.” At the time of the report, the 141 caches had an estimated 6.1 million units of expired drugs.
VA Acting Under Secretary for Health Richard Stone, MD, committed the VHA to addressing all the issues raised by the IG report by September 2019.
As for the fourth assumption in the COVID-19 response plan, the department has moved to address potential staffing shortages. In March, the VA received a waiver from the Office of Personnel Management to rehire retired VA healthcare workers, including pharmacists and laboratory technicians.
- O’Donovan A, Cohen BE, Seal KH, et al. Elevated risk for autoimmune disorders in Iraq and Afghanistan veterans with posttraumatic stress disorder. Biol Psychiatry. 2015;77(4):365–374.
- Gautret P, Lagier JC, Parola P, Hoang VT, et. Hydroxychloroquine and azithromycin as a treatment of COVID-19: results of an open-label non-randomized clinical trial. Int J Antimicrob Agents. 2020 Mar 20:105949.
- Wang M, Cao R, Zhang L, Yang X, Liu J, Xu M, Shi Z, Hu Z, Zhong W, Xiao G. Remdesivir and chloroquine effectively inhibit the recently emerged novel coronavirus (2019-nCoV) in vitro. Cell Res. 2020 Mar;30(3):269-271.
