Role of the SNS in Incident Response

Requesting the Strategic National Stockpile

Figure 3 illustrates the process for requesting SNS supplies. The decision to deploy is a collaborative effort between local, state, and Federal officials. Local officials who identify a potential or actual problem that will exceed the resource capacity should contact their health department or state emergency management officials, who in turn can alert the governor, who can request the SNS directly through the DHS/CDC or as part of a formal request for Federal assistance through the national emergency response system.

Figure 3 – The tiered decision-making and communication process allows for express delivery of medical supplies and prevents a hasty or unwarranted call to arms.

The director of the CDC will quickly evaluate the request; if local resources are deemed insufficient, the SNS will be deployed. Not all requests will result in SNS deployment. While the CDC has the lead role in deployment of the SNS, the DHS, because of its functional expertise, is the nominal and legal lead. The CDC will assume the lead in deploying the SNS for local use, but coordination with the DHS remains an essential element of an effective response.

The requirement for collaboration at the local, state, and Federal level means that effective deployment of the SNS will need an expedited communication process between all parties. This is an area where exercises and testing of the plans, policies, and procedures on an ongoing basis can be of great value—any local or state exercise involving an incident that could require the deployment of the SNS would benefit from specific assessment of how the request would be coordinated by the various parties.

Storage and Deployment

Push packages are described as containing "a little bit of everything” to augment local supplies and meet general emergency needs. If a locality knows in advance the specific pharmaceuticals it needs, it may request aid from the VMI component of the SNS. VMI is a cushion that can be accessed rapidly in times of crisis. Emergency supplies of ciprofloxacin, for example, were made available from VMI in the wake of the 2001 anthrax exposures. After the delivery of a push package, follow-on supplies from VMI are delivered within 24-36 hours of the initial request. Alternatively, VMI may serve as an initial, tailored response to an event involving a known agent. VMI also provides a means by which the government can limit the cost of buying, storing, and managing stocks. Costs would increase if the government purchased materials that it ultimately had to destroy because they were too much to reinsert into ordinary medical distribution channels.

The CDC website indicates that state and local authorities repackage bulk medicines and label them and other medical supplies in accordance with the state’s terrorism contingency plans. The CDC transfers authority for the materials to state and local authorities on arrival. It also provides a Technical Advisory Response Unit (TARU), a team of 5 or 6 pharmacists, emergency responders, and logistics experts, to assist state and local officials when stockpiled supplies are deployed. 7

The delivery and receipt of a push package is a complex, collaborative effort that requires significant coordination. The best time to plan and train for such an effort is now, rather than during the next crisis. The need for proactive planning cannot be over-emphasized; lack of planning remains a potential point of weakness for many locations around the nation. The state and local responsibilities for the SNS can vary from state to state. Not all states have resolved how to deal with the SNS. One area of concern is the fact that some states with extensive military air bases incorrectly believe that using these facilities offers the best route for SNS receipt and local distribution. The CDC advises that “military airfields (are) the absolutely last alternative,” for reasons discussed below.

By whatever means, delivery of packages is a significant logistical challenge. The CDC guidance is that the initial site for receipt, storage, and staging of the SNS requires 12,000 square feet of floor space and must include temperature/humidity control, emergency electrical power, security, and an area for storage of controlled substances. Push packages contain three controlled substances: morphine, diazepam, and lorazepam. While they only occupy approximately 18 cubic feet of the package, they require considerable control and regulation in terms of distribution. Any person handling or using the drugs, even under conditions of crisis, must be registered with the Drug Enforcement Agency.

Distribution

Distribution of stocks is the responsibility of the state or locality that receives the push packages. It is often recommended that after receipt of the package the state use its agencies—state police, National Guard, etc.—to coordinate the staging, distribution, and dispensing of SNS materials. For instance, it would seem sensible to task law enforcement agencies to provide security for the push package. This type of coordination needs to be planned ahead of time, and the tasks that require support should be made clear to all parties. Equally, the use of state and local resources will help in ensuring that there is adequate and effective communication between the various parties engaged in distribution of the push package contents.

When the CDC deployed the National Pharmaceutical Stockpile after the terrorist attacks in the fall of 2001, most of the medications were in bulk containers of thousands of tablets and capsules, which poses a problem when trying to dispense prescription drugs in an emergency situation. Since then the stockpile has been modified. The CDC contracted vendors to package 50 percent of the anti-infective stocks, including doxycycline, ciprofloxacin, and amoxicillin, into 10- or 25-day-supply, unit-of-use bottles that are replicas of the larger manufacturer-made containers. Each push package now contains two high-speed, industrial repackaging machines that can produce 5,000 unit-of-use sealed bags of medications per hour. Although a TARU will assist workers and operate machines if necessary, the mission’s efficiency depends heavily on local infrastructure and planning. The TARU team cannot expediently distribute the mass of supplies and equipment without highly trained emergency management workers on hand to greet them. The CDC also has updated its stockpile guide with new information that includes dispensing information for the medications. 8

Utilization

Because of the need to cover many eventualities, the SNS will provide more of some materials than are required for response to an incident. This leaves an issue of leftover supplies. Under normal circumstances, the CDC expects leftover stockpile supplies to be absorbed by the local health care system and used by community and state medical personnel, rather than shipped back to their point of origin. It is possible however, that unused supplies could be returned to the CDC, if materials had been stored properly and had not been compromised. Reabsorbtion of SNS materials would be assessed on a case-by-case basis. The materials that are supplied in the SNS are meticulously packaged and configured in a certain manner. If that configuration is compromised in any way or if any of the boxes are unsealed, those materials are not returned to the stockpile.

With respect to VMI, it is also possible for the CDC to resell to the vendors unused medical supplies and pharmaceuticals, as long as they are at least six months from their expiration date and still in the sealed, original packages.

7. Twelve TARU teams exist, each assigned to a different push package, and all based at the CDC’s headquarters in Atlanta, Georgia.
8. The CDC guide is not available to the general public, but pharmacists may obtain a copy by requesting it from a local emergency management or public health agency.