How would emergency management and public health officials handle a catastrophe that taxed local supplies of vaccines or medical equipment? Since 1999, the federal government has had a way to help: the Strategic National Stockpile.
The stockpile consists of warehouses that contain medicines — both those that prevent the onset of an illness and those that can treat illnesses — and medical supplies and equipment. It is not meant to be the first line of defense, but rather to supplement resources when state and local supplies run short.
“The underlying premise of the Strategic National Stockpile is to respond to primarily chemical, biological, radiological and nuclear events,” said Greg Burel, director of the Division of Strategic National Stockpile at the Centers for Disease Control and Prevention (CDC). “We also hold material that would be useful in an influenza event.”
The exact number of warehouses, the contents and the locations are not made public, though the CDC’s website describes the contents as “antibiotics, chemical antidotes, antitoxins, life-support medications, IV administration, airway maintenance supplies and medical/surgical items.”
“There are multiple locations across the country,” Burel said. The sites are selected after considering factors such as population density, the availability of major transportation hubs and risk factors like natural disasters. “We try to balance products in a way across these warehouses to get the most rapid distribution anywhere in the country we need to get to.”
There’s a reason for the secrecy.
“If you know what’s in it, you know what’s not in it, which could suggest some vulnerabilities,” said Rocco Casagrande, managing director of Gryphon Scientific in Takoma Park, Md. “It would describe exactly which attacks we don’t have preparations for.”
The way the stockpile’s contents are chosen illustrates the complexity of the decisions officials face when preparing for public health emergencies.
Irwin Redlener, director of the National Center for Disaster Preparedness at Columbia University, said choosing items for the stockpile is one of the key challenges. The other is what happens at the end of the process: the management of the so-called last mile, where supplies are distributed to those who need them.
The Strategic National Stockpile is just one part of the overall plan for getting supplemental emergency assistance to areas that need it. The process begins with the Public Health Emergency Medical Countermeasures Enterprise (PHEMCE), the government organization that makes decisions about what should be in the stockpile.
“What conditions will it respond to? What supplies and medical countermeasures need to be in the stockpiles?” Redlener said. PHEMCE makes this determination.
Although the original goal of the Strategic National Stockpile was to respond to chemical, biological, radiological and nuclear threats, Burel said, “we have expanded our mission to an all-hazards perspective, so we do hold some products that are useful, for example, in response to hurricanes and earthquakes.”
The list of what goes into the Strategic National Stockpile is based on material threat assessments from the Department of Homeland Security, as well as medical information.
“The content changes over time based on scientific understanding of what is needed to combat the material threats,” Burel said. The threats themselves don’t change dramatically very often, he said, but “if some new threat appeared and became the highest priority, we could have to make rapid changes in our holdings to address that.”
The Strategic National Stockpile is responsible for the middle part of the process: maintaining the inventory and making sure it can get where it’s needed. But the stockpile’s responsibility for the materials ends once it is delivered to the local authorities, who distribute them to the people who need them.
“The [Strategic National Stockpile] portion is important, but it depends on what happens before and after,” Redlener said.
The current valuation of the stockpile’s inventory, which includes enough medicine for the populations of several large cities, is about $7.5 billion, and the average annual appropriation for it is about $500 million.
Experts deciding what should go into the stockpile have to consider many factors, including current threats, the availability of products, how easily the products can be distributed and the medical vulnerability of the population, according to the CDC. They also look at how useful specific items will be in a range of situations.
For example, some antibiotics may be useful to combat a broad range of threats — though not always with a big impact — whereas an antitoxin may be more effective but useful in just one type of emergency. In addition, “there might be certain agents that act so fast that it doesn’t make sense to stockpile countermeasures for them because you can’t get them there,” said Casagrande.
Some of the products may also serve multiple purposes: Oral antibiotics, for example, may be put in the stockpile in preparation for a particular type of biological weapon attack. “It may be that they would be useful for a large-scale emerging infectious disease or some man-made event that we didn’t plan for,” Burel said. “We are constantly looking for ways to make sure we can get the most use out of everything we own.”
The program works with commercial vendors to provide some of the material, sometimes in response to emerging threats.
For example, during the Ebola outbreak, the Strategic National Stockpile used the commercial supply chain to provide protective gear to health-care workers, according to a report prepared for a PHEMCE workshop in January.
“With Ebola, we did acquire on the fly a small stock of personal protective equipment,” said Burel. After officials determined which hospitals would play which role in treating Ebola patients, “we worked with hospitals directly to determine what their status was to be able to support patients.”
One key aspect of the stockpile program is quality assurance. This means rotating the stock to replace anything that has expired, for example, and performing quarterly quality assurance checks. In addition, changes are made due to new drugs that have been developed to combat certain diseases.
The materials in the stockpile will only be effective in an emergency if they actually get to the people who need them in time.
Casagrande said the key is the “three D’s”: delivery, or getting the material from the stockpile to the local area; distribution, which means getting it to the specific place where it will be used; and dispensing, or administering it to the patient. “All three are important,” he said.
This process starts once local and state resources are exhausted. The governor of the affected state requests material from the stockpile from the CDC or the U.S. Department of Health and Human Services, starting a rapid decision-making process to determine what type of help can be provided. At the end of the chain, local communities receive the materials from the state and provide them to those who need them in the community.
“We work with state and local officials to determine where to deliver it and how to do that,” Burel said. For most situations, plans are already in place for the local agencies to distribute the products once they receive them.
The level of preparation among states and local governments varies. “We have some states and localities where the coordination is very advanced,” Burel said. “There are some that probably need a little more work in that area.”
Once the material arrives at the affected area, state and local officials take control of it. However, the stockpile does provide technical advisers who can assist the local jurisdictions in getting the material to where it’s needed.
“Once we hand off the material, we don’t just walk away,” Burel said. “But it becomes the responsibility of state and local officials to put material into distribution plans they already have in place.”
The stockpile has several ways of getting material to those who need it. For immediate response, it has 12-hour Push Packages, which the CDC describes as “caches of pharmaceuticals, antidotes and medical supplies designed to provide rapid delivery of a broad spectrum of assets for an ill-defined threat in the early hours of an event.” They can be loaded onto trucks or cargo planes to be delivered within 12 hours of the decision to use them.
The CDC also uses vendor-managed inventory, which can get to an affected location within 24 to 36 hours.
The stockpile staff also provides assistance to public health and emergency management departments to handle emerging threats. “We’ve been able to work through our capability to manage medical supply chain logistics and try to help make sure that interventions are conducted in the most rational way,” Burel said.
As the Strategic National Stockpile moves into the future, there are questions about what might change.
“We don’t really have an agency that has the job of overseeing, end to end, the determination of threats, selection of countermeasures, the stockpile and the last mile. I do believe there could be an agency with end-to-end responsibility,” said Redlener. The management structure of the entire process is “one of the open questions for a new administration.”
“We’re constantly looking for ways to do better, to make things move faster,” Burel said. For example, they are starting to do exercises with external partner groups such as the Health Industry Distributors Association. “Whether it’s a natural or man-made disaster, a weather event or an earthquake or a disease — what is the best way we can all work together make decisions?”
For now and in the future, communication among agencies is key.
“It’s very important for the public health community and the emergency management community to talk in advance about how they can support each other,” Burel said. “Even these natural disasters all have significant public health implications. If you’re in emergency management, you can’t think of emergency management in a vacuum. You have to think about how it’s going to impact public health.”