If there were to be a major earthquake, flu outbreak, or terrorist attack in one or more of the nation’s largest cities tomorrow, gaining access to life-saving medications may seem impossible. Thankfully, the strategic national stockpile (SNS) is in place in case of an emergency. The mission of the SNS program is to “deliver critical medical assets to the site of a national emergency.”1 Despite the fact that the national stockpile contains more than $1 billion worth of medications, most pharmacists are unaware of the stockpile and do not know what would happen during an emergency.
The Centers for Disease Control and Prevention (CDC), a division of the US Department of Health and Human Services, manages the SNS in coordination with the US Department of Homeland Security. An individual retail pharmacy cannot request medications from the SNS, however. Requests for products from the SNS must come from a state’s department of health, usually in coordination with the governor’s office, or from a national agency, such as the Federal Emergency Management Agency. Any local requests for SNS medications must first be approved at the state level. Although the government has classified SNS locations for security reasons, once they make the decision to deploy drugs, medications can be delivered to any area of the country within 12 hours. Healthcare workers can then dispense and administer the SNS medications to qualifying individuals free of charge.
Although the public does not have access to the exact SNS formulary, many of the medications included in the SNS are known, and others can likely be guessed based on the stockpile’s purpose. Category A threat agents include those used to treat smallpox, botulism, anthrax, plague, tularemia, and others. To combat these diseases, as well as to prepare for a nuclear attack or natural disaster, the inventory in the SNS contains an array of medications. The CDC is constantly evaluating current biological and chemical threats and determining the medical vulnerability of the US population in order to keep the SNS adequately stocked. The CDC also performs quality assurance and quality control checks quarterly, and they complete a 100% inventory inspection annually. Because the SNS inventory encompasses approximately 500,000 square feet of warehouse space, this can be a large task. The SNS inventory is also divided between multiple locations, and consists of both 12-hour “push packages” and managed inventory.
When the exact nature of the disaster is unknown, prepackaged 12-hour push packages can be sent to the disaster site. The push packages contain oral and intravenous (IV) antibiotics, emergency medications, IV fluids and administration sets, airway equipment, and bandages, and are stored in different, nondescript locations across the country near major transportation hubs. For security reasons, armed guards protect the facilities.
Push packages serve as a first-line medical response measure and constitute approximately 5% of the SNS inventory. When the exact nature of the disaster or threat is known, managed inventory also can be sent within 24 to 36 hours to treat specific health conditions. Managed inventory would likely include vaccines, antitoxins, ventilators, surgical supplies, painkillers, epinephrine, and other drugs and supplies.
Although tragic, after Hurricane Katrina hit the Gulf Coast, the United States was better prepared to deal with emergency public health responses. One of the major lessons learned from the hurricane response involved the need for medications to treat chronic health conditions. The original intent of the SNS was to respond to the immediate, critical needs of patients. However, as seen with Hurricane Katrina, people affected by natural disasters may be without chronic medications for days or even weeks. While we may not think of medications like insulin and beta-blockers as emergency preparedness medications, the experiences of those in Katrina have caused the CDC to reevaluate the expansion of the SNS formulary to include medications to treat chronic conditions. One positive outcome from Hurricane Katrina was the creation of KatrinaHealth, a web portal that combined prescription data from a number of sources including Medicaid, Veterans Affairs, commercial payers, and retail pharmacies. This enabled evacuees to have their prescription and medical information accessed out of state by any authorized physician or pharmacist providing them care. Should another disaster strike, this portal will likely serve as a model for others.
Likewise, when the H1N1 flu pandemic struck in 2009, the SNS was used to supply approximately 11 million doses of oseltamivir (Tamiflu) and zanamivir (Relenza) across all 50 states. The SNS currently has approximately 80 million courses of oseltamivir and zanamivir therapy stockpiled. This would be enough to treat approximately 25% of the US population if another pandemic occurred. While it may seem strange that only 25% of the population could receive the antivirals, it is important to remember that even in the severe 1918 influenza pandemic, only 30% of the nation contracted the disease. Thus, a supply of 80 million courses of antiviral therapy is most likely sufficient.
While it is great to have an SNS in place, if those who need the medications are unable to get them, the drugs are of little value. This raises the question of how emergency medications will be delivered, distributed, and administered to the patients who need them most during a disaster. Once federal authorities approve the deployment of SNS medications, unmarked trucks and/or airplanes will deliver the drug products to their state destination. After that, each state has its own plan in place for receiving and distributing the medications locally. States will have certain predetermined dispensing locations, such as local hospitals or clinics, where they will deliver the medications. As made apparent by the H1N1 vaccine distribution in 2009, communication between federal, state, and local health departments is extremely important. The H1N1 experience has led to an increase in strategic planning to strengthen weak communication channels.
While state officials may provide technical support, it is the responsibility of local jurisdiction personnel to actually dispense and administer the medications. Local methods for administering vaccines and other medications vary. Traditional methods of administering vaccines include publicizing set administration times at local hospitals and health clinics. Many areas of the country have also developed nontraditional plans. Some local governments have created partnerships with schools, nursing homes, jails, or businesses, whereby these facilities would administer the vaccines to their own residents in case of an emergency. Other local governments in Florida and Kentucky have planned to operate drive-through dispensing clinics, which would function much like fast-food restaurant drive-through windows. To receive information about procuring the SNS medications, the public should watch television, listen to the radio, or check community websites or newspapers for public service instructions during a disaster.
While it may sound like a smooth and well-thought-out process, without trained staff, reacting to an emergency can be difficult. US Public Health Service workers and the states’ Department of Health workers are all trained to serve in these types of situations. These departments will probably be the first to provide staffing support in case of an emergency. However, during large disasters, additional staff may be needed to help sort, dispense, and administer medications. Much of this additional help comes in the form of volunteers. Most states have an online registry for medical and nonmedical emergency disaster responders. Anyone can register, and those who do register are not obligated to participate in emergency response initiatives. The registry simply makes it easier for the state to reach out for help, should a disaster strike. Volunteer positions that may be crucial in case of an emergency include triage greeters, pharmacy unit leaders, pharmacy technicians, and dispensing personnel. If you are interested in becoming an emergency disaster responder, visit your state’s Department of Health website for more information.
Although the thought of a natural disaster, terrorist attack, or disease epidemic makes everyone nervous, there is some solace in the fact that a SNS is in place with plans to distribute and administer drugs to the public should they be needed. Because of their frequent patient interactions and connections with many healthcare providers, pharmacists are uniquely situated to play a key role during these situations. Whether you will be working as an emergency disaster responder, collaborating with public health workers, or simply answering questions for patients and their families during an emergency, being informed about the SNS is vital during a disaster. Being able to disseminate information and explain the government’s plan of action can go a long way toward calming the fears of others during an emergency. Besides, when a disaster strikes, if you have failed to plan, you plan to fail.
- Centers for Disease Control and Prevention. Office of Public Health Preparedness and Response. Strategic National Stockpile fact sheet. http://www.cdc.gov/phpr/stockpile/stockpile.htm. Accessed June 24, 2013.