Posts Tagged ‘medications’

Smallpox lesions. Photo by CDC/Dr. Robinson.

Smallpox lesions. Photo by CDC/Dr. Robinson.

Raise Your Hand if You’ve Heard of the Strategic National Stockpile

Until my involvement in disaster preparedness, I was unaware of the Strategic National Stockpile (SNS). In fact, it wasn’t until my Advanced Disaster Life Support class that it was first mentioned. It took some digging to discover more than superficial information on-line – unusual for federal preparedness programs! Perhaps the SNS role in treatment for biological, chemical, and nuclear terrorism promotes a cloud of secrecy. Per the Centers for Disease Control (CDC), an “act of terrorism (or a large-scale natural disaster) targeting the U.S. civilian population will require rapid access to large quantities of pharmaceuticals and medical supplies”. (I love how natural disasters seem almost like an afterthought in this statement). These supplies could be crucial in any disaster, natural or man-made, so let’s clear away some of the mist.

The SNS is a national repository of antibiotics, antidotes, antitoxins, life-support medications, intravenous fluids, and medical/surgical supplies and equipment – a giant emergency medical supply cache. It began in 1999 as the National Pharmaceutical Stockpile, morphing to the current Strategic National Stockpile program in 2003. Ownership bounced around a bit, but currently it belongs to the  Centers for Disease Control (CDC) – after all, pandemic or bioterrorism response is classic CDC territory! On a state or local level, the SNS falls in the lap of public health.

What’s in the Strategic National Stockpile?

Loading part of a SNS delivery on an unmarked truck.

Loading part of a SNS delivery on an unmarked truck.

SNS contents are classified, although the CDC says they “reflect current biological and/or chemical threats, the availability of medical materials, the ease of dissemination of pharmaceuticals, and assessment of the medical vulnerability of the U.S. civilian population” – nothing like plain English! They claim the stockpile has enough medicine to protect people in several large cities simultaneously. Perhaps the contents are kept intentionally vague to block terrorists from learning our level of preparedness?

Here is the most specific list I could compile (I’d like to know what I might have access to).

  • Prepackaged, individual 10-day antibiotic regiments for over 300,000 people
  • Broad spectrum antibiotics and antivirals like Tamiflu
  • Chemical agent antidotes, antitoxins, and vaccines (including over 200 million smallpox vaccines)
  • Radiation, burn and blast supplies
  • Wound care bandages and antibiotic ointments
  • Laceration repair kits with sutures and skin staplers
  • Lidocaine with and without epinephrine
  • Intravenous fluids
  • Oxycodone/Acetaminophen, morphine, and midazolam
  • Ventilators and oxygen cannulas/masks
  • Albuterol solutions and nebulizers
  • Suction set-upand nasogastric tubes

Like other disasters, the governor requests federal deployment of the SNS, but this is one case where a federal disaster declaration isn’t needed (although you shouldn’t request it unless state resources are inadequate). When local officials identify a potential health threat (from disease tracking or intelligence reports), deciding to send out the SNS at the suspicion stage might be better than waiting for full-blown disaster. “Prophylactic” deployment of the SNS has been used for major events with terrorism security risks, such as national political conventions and the Olympics. I’m not sure if that’s a comfort or not!

Photo by UK Ministry of Defence

Photo by UK Ministry of Defence

Push Packages – 12 and 12

In 12 secret warehouse locations around the country, the SNS stores “push packages”, designed for delivery within 12 hours after request (I wouldn’t count on 12 hours.  A better plan is preparing for 36-48 hours: 12 – 24 hours for SNS state delivery, and another 12-24 hours for local distribution). These so-called packages contain 50 tons of assorted emergency medications, supplies, and equipment packed in 130 cargo containers –anything you might want on your disaster Christmas list. It takes 1 wide-body jet or 9 semis (unmarked and guarded) to transport a single “package” – definitely not something “brown can do for you”. Each state defines a delivery site, hopefully with alternatives for when the first one bites it in a disaster. (The Portland airport won’t outlast our Cascadia earthquake. It’s built on soil that will turn to soup with a good strong shake!)

The state distributes a pallet from the SNS to one local health department and one hospital per county. If there is not enough to go around, the first round is allocated by population. Big cities get priority for limited resources. It seems unfair, but really it’s just another type of triage – do the most good for the greatest number of patients!

The Second Line

Besides push packages, the SNS stores other supplies in government managed warehouses, plus vendor managed inventory (stored by manufacturers, but owned by the government). These secondary supplies can target specific needs based on the type of disaster (smallpox vaccine, anyone?). They arrive 24 to 36 hours after a disaster, again via guarded unmarked trucks – got to love that security!

Once adequate inventory is available in the state, hospitals and health departments (and maybe even the medical reserve corps) can request specific supplies, particularly if they missed out on the first go around. If needed items are not available in the SNS, the federal government will supposedly buy and deliver them from the private sector.


In case of chemical exposure, waiting 12 hours for a push package is too long. Victims need rapid treatment or they die. Special caches of chemical antidotes and treatment are stashed in strategic hospitals around the country. Security is tight – chempacks require storage in secure environmentally controlled rooms, complete with intruder alerts. Opening happens only by instruction from the incident commander, emergency manager, or by an emergency physician or pharmacist identifying an immediate threat to human life. Chempack contents include kits for distribution to emergency medical responders for use in the field and to other regional hospitals if needed for a surge of patients.

A Logistical Nightmare

Waiting in line for H1N1 vaccine - not a smooth running process. Photo by WVCowboy.

Waiting in line for H1N1 vaccine – not a smooth running process. Photo by WVCowboy.

It isn’t easy maintaining a SNS. Identifying necessary supplies in advance requires both research and guesswork (kind of like designing each year’s flu vaccine). Medications require regular rotation to stay within shelf-life potency limits – and you thought rotating personal stores was difficult! Medication rotation is so expensive that the SNS and the Food and Drug Administration (FDA) created a list of medications that are kept longer than the official expiration date – for war and disaster use only. (Now I can rationalize not cleaning out my medicine cabinet.) The SNS also checks and restocks chempacks around the country – it’s too important to defer this to the local host.

A state receiving supplies from the SNS faces a logistical problem of nightmarish proportion. One push package alone requires 12,000 square feet of floor space for receiving, staging and storing. Supplies must be unpacked, inventoried, and distributed throughout the state, each step associated with a mound of regulations and paperwork. The stockpile includes controlled substances like narcotics and sedatives, so Drug Enforcement Agency (DEA) regulations regarding security, tracking, and licensing kick in at both state and local distribution centers. Occasionally, repackaging of medication is needed, requiring pharmacist supervision, and a huge set of FDA guidelines. It’s all so complicated that a Stockpile Service Advance Group arrives with the push package, just to walk the locals through the process.

Limits of the Strategic National Stockpile

Part of a Push Package

Part of a Push Package

First and foremost, the SNS doesn’t include routine pharmaceuticals, like heart or depression meds. No one has quite figured out how you’ll obtain these if a large disaster interrupts pharmacy deliveries. Try to accumulate a month’s supply of your own essential medications (I know insurance doesn’t usually cover this, but many allow you to refill a few days early. If you routinely do this, you can build up a month’s supply over a year. Just remember to keep rotating meds –  just like the SNS).

Regulations about medications in the United States are the tightest in the world – who makes them, how they’re made and stored, who can get access to them (doctors prescribe but usually can’t distribute or store meds beyond samples – that’s what pharmacists are for), how they’re tracked, insurance limits, and on and on, and on. In normal times, medication regulations are a bane of the doctor’s existence. Although the rules make some sense for safety in a safe world, the same rules create barriers in a disaster setting. One would hope the FDA and DEA might relax pharmaceutical standards of care in disasters, but it’s not part of the plan for now. (My pet peeve – how to access adequate narcotics for mass casualty pain outside the hospital. Broken bones, guts hanging out – I’m sorry!)

Money, money, money. Large amounts of federal money were initially spent on the SNS, including support for states to develop training programs and local supply caches. Now federal funding only goes to 72 large cities (which account for over 50% of the country’s population). If you live elsewhere…! All other state SNS funding mixes in with general health preparedness funds, which are also dwindling. The stockpile is still there, but statewide preparedness to handle it efficiently may fade away. Unfortunately, until we have another 9/11 or Katrina to wake people up, governmental funding for preparedness just isn’t a priority.

Rest assured – in case of anthrax, nerve agent, or smallpox attack, there is a plan (there might even be one for a natural disaster). Secret supplies are available, hidden in secret locations, with secret plans to get them to you. May your community never need to use them!

Stay safe,

Sheila Sund, M.D.