Feature Articles The Strategic National Stockpile: Roles and Responsibilities of Health Care Professionals for Receiving the Stockpile Assets Debraelee Esbitt, RN In 1999, the US Congress created the National Pharmaceutical Stockpile Program (NPS) under the management of the Centers for Disease Control and Prevention (CDC) and the Department of Health and Human Services. On March 1, 2003, the National Pharmaceutical Stockpile Program became known as the Strategic National Stockpile (SNS) Program under the new Department of Homeland Security. The purpose of the SNS Program is to maintain a stockpile of pharmaceutical agents, vaccines, medical supplies, and equipment to augment state and local resources during a large-scale disaster or bioterrorism event. Upon request, the SNS Program will deliver materials anywhere in the United States within 12 or fewer hours. A brief overview of the SNS Program and the role of local and state health care providers for receiving the SNS assets are reviewed. (Disaster Manage Response 2003;1:68-70.) I n 1999, the US Congress, anticipating the states’ need for additional supplies during a large-scale disaster or bioterrorism event, mandated the formation of the National Pharmaceutical Stockpile Program (NPS). The program was established to oversee the stockpile of pharmaceutical agents, vaccines, medical supplies, and equipment and make them immediately available once state and local supplies have been depleted. On March 1, 2003, the National Pharmaceutical Stockpile Program became known as the Strategic National Stockpile Program and became part of the new Department of Homeland Security. The departments of Homeland Security and Health and Human Services now work collaboratively to manage Stockpile resources and operations. MISSION AND STRUCTURE OF SNS PROGRAM The mission of the SNS Program is to deliver pharmaceutical agents and other medical materiels to a site of a national emergency. The SNS is to be rapidly deployed, dispensed, and administered at the location of a large-scale disaster or chemical or biologic terrorism event. During an Debraelee Esbitt, RN, is a health scientist at the Strategic National Stockpile Program, Centers for Disease Control and Prevention, Atlanta, Georgia. Reprint requests: Debraelee Esbitt, RN, 1600 Clifton Road N.E., MS D-08, Atlanta, Georgia 30333. (E-mail dhe1@cdc.gov) Copyright 䊚 2003 by the Emergency Nurses Association 1540-2487/2003/$30.00 ⫹ 0 doi:10.1016/S1540-2487(03)00044-0 68 Disaster Management & Response/Esbitt event, the SNS Program will deliver its life-saving medical supplies to the requesting state within 12 hours of the federal decision to deploy. In fact, the SNS Program’s rapid buying power and surge capacity mechanisms allow for continued purchase and shipments of additional medical materiels until supplies are no longer needed. The SNS Program will deliver its life-saving medical supplies to the requesting state within 12 hours. 12-hour Push Package The 12-hour Push Package is named accordingly because the materiel can be “pushed out” (or shipped) to the affected state and received within 12 hours of the federal decision to deploy the assets. There are a total of twelve 12-hour Push Packages (Photo 1) that are strategically located throughout the United States, thereby enabling air or ground delivery to any state or US territory in 12 or fewer hours. The 12-hour Push Package has more than 100 containers and weighs approximately 50 tons. It holds large quantities of pharmaceutical agents, medical supplies, and equipment—nearly everything that is needed for an initial emergency response. Since a 12-hour Push Package contains a broad range of supplies needed to treat injuries caused by biologic and chemical nerve agents, it will be deployed when the threat agent is not known. Contents of a 12-hour Push Package. Pharmaceutical agents in the SNS formulary are selected on the basis of Volume 1, Number 3 12-hour Push Package to New York. The SNS Program sent a team of technical advisors who arrived on the scene just 5 hours after receiving the deployment order, and the 12-hour Push Package arrived 2 hours later. Similarly, materiel from the SNS Program’s VMI was used to help several affected states during the anthrax events of the same year. More than 50 requests for antibiotic agents specific for treating anthrax were shipped directly from VMI to 11 states and the District of Colombia. The average delivery time for each shipment was less than 5 hours. REQUESTING THE SNS ASSETS Photo 1. One 12-hour Push Package contains more than 100 cargo containers and weighs approximately 50 tons. Each container is on wheels and can be easily maneuvered by 1 or 2 people. The 12-hour Push Package is designed to be loaded into a cargo airplane or into tractor-trailer units. Photo courtesy of the SNS program. their ability to reduce morbidity and mortality from threat agents within a targeted population, suitability for stock rotation, storage requirements, Food and Drug Administration status and indication for the disease agent, and costs. One 12-hour Push Package contains unit-of-use and bulk oral antibiotic agents, oral antibiotic suspensions and syrups, intravenous and intramuscular injection medications, analgesic agents, and other emergency medications. A 12-hour Push Package also includes equipment to be used in a mass casualty event. This equipment includes tablet-counting machines; volumetric counting devices; an Automated Packaging System (APS); and medical supplies to assist in intravenous administration, airway management, and trauma care. Medical supplies are available in both adult and pediatric sizes. Vendor Managed Inventory Vendor Managed Inventory (VMI) consists of large reserves of federally owned inventory that is stored at vendor sites until needed. These reserves include everything found in a 12-hour Push Package and more. VMI will be used to provide specific pharmaceutical and medical supplies if the agent is known or in cases when medical materiels are needed for a small-scale event that does not warrant the movement of an entire 12-hour Push Package. If used as follow-up to the 12-hour Push Package, VMI assets can serve to resupply the inventory at the scene and arrive on site within 24 to 36 hours. If VMI is needed for an initial response, the SNS-Program’s goal is to ship these assets to an affected site in 12 hours, similar to the timeframe of delivering a 12-hour Push Package. In addition, the SNS Program stockpiles antitoxins and vaccines for Category A biologic threat agents and will deliver these to the affected areas separately, as needed. On September 11, 2001, the SNS Program delivered a July-September 2003 Local and state authorities may request a 12-hour Push Package or VMI materiel once a potential or real threat has been identified that would require the need for supplemental pharmaceutical and medical supplies. The affected state’s governor must request SNS assets from the director of the Centers for Disease Control and Prevention (CDC). The CDC director will evaluate the request with local, state, and federal officials and release the SNS assets if local and state resources are deemed insufficient. Space Requirements The delivery site for a 12-hour Push Package or VMI material needs to be approximately 12,000 square feet. This amount of space is needed for storing SNS assets, performing inventory control and allocation of the materiel, distributing supplies, and repackaging bulk antibiotic agents if needed. The SNS Program will provide assistance to state SNS planners to determine a suitable receiving-site facility. Technical Advisory Response Unit During an event, the SNS Program will deploy a team of advisors to provide technical assistance to the states. The Technical Advisory Response Unit (TARU) is composed of 5 to 7 experts in emergency response, operations, communications, logistics and public health. The team also may include a pharmacist, health care clinician, or media relations expert. The TARU will be deployed to the site to assist state and local authorities in receiving, managing, distributing, dispensing, and replenishing the SNS. If repackaging of bulk medication is needed, the TARU can provide assistance in operating the repackaging equipment. The TARU also will assist in recovering unused SNS assets and material belonging to the SNS Program, such as cargo containers and support equipment. PREPARING HEALTH CARE PROVIDERS TO WORK WITH THE SNS Although the SNS Program will deliver medical materiels as needed, it relies on state and local health care professionals to distribute and dispense the materiel to the public. Health care professionals also will assist their state in receiving and storing the SNS materiels and need to be prepared before and during a mass casualty event. In 2002, $65 million in federal grant money was awarded to states to prepare for receiving the SNS materiel. Each state, Disaster Management & Response/Esbitt 69 with guidance from the SNS Program, is responsible for developing its own plan for receiving, storing, distributing, and dispensing the SNS assets. Each state develops its plan on the basis of its own resources and populations and must be able to perform functions successfully. Physicians, pharmacists, and nurses will need to be familiar with their state’s emergency plan and their specific roles and responsibilities for receiving the SNS assets. Roles will be assigned according to the individual’s qualifications and credentials. States will need nurses, pharmacists, and physicians to run dispensing sites but may assign nonmedical volunteers to help apportion SNS supplies, operate industrial machinery (eg, forklifts), or assist with crowd control. Local and state agencies will need help to move the SNS assets from inside the cargo containers; apportion supplies; process requests from dispensing sites and treatment centers; record, track, and monitor distributed supplies; and recover unused SNS materiel. Health professionals not working in hospitals or at treatment centers may be working at dispensing sites. Here, they will be responsible for briefing the public about the agent, providing drug information, triaging patients, recording history and physical information from patients, obtaining signed consent forms for Investigational New Drug (IND) medications, dispensing pharmaceutical agents, or managing dispensing sites. Although the majority of oral antibiotic agents in the SNS are provided in unit-of-use containers, health professionals may be required to repackage bulk antibiotic agents. This would occur if the demand exceeds supply of unit-of-use prepackaged antibiotic agents or if the available antibiotic agents are found to be ineffective against a particular threat agent and different antibiotic agents are available only in bulk. Chemical and Biologic Agents, Treatment Guidelines, and Exercises To help facilitate a rapid response when the SNS assets are to be used, physicians, pharmacists, and nurses must be knowledgeable of the potential bioterrorism threat agents and their treatment guidelines. They also should participate in their state’s bioterrorism and disaster exercises. Types of agents. The SNS Program has stockpiled pharmaceutical agents, vaccines, antitoxins, and medical supplies for chemical nerve agents (eg, sarin, soman, sabun, and VX) and biological Category A threat agents. Category A biologic threat agents include anthrax, botulism, plague, smallpox, tularemia, and hemorrhagic fever viruses. Category A agents, as defined by the CDC, are those agents that cause the highest threat on the basis of the potential to deliver the agent to large populations and produce mass casualties if disseminated. Category A agents also require increased public health preparedness efforts (eg, stockpiling medications) and have the potential to cause civil disruption.1 70 Disaster Management & Response/Esbitt Treatment protocols. Health care professionals must know the prophylaxis and treatment regimens recommended for patients potentially or actually exposed to chemical nerve and biologic Category A threat agents. Web sources for these treatment guidelines can be found at www.bt.cdc.gov and the Journal of the American Medical Association’s (JAMA) site at http://jama.ama-assn.org. These sites provide information about each of the different threat agents, including their history, clinical manifestations, epidemiologic factors, diagnosis, and therapy. Disaster Drills In addition to the local or state emergency preparedness exercises, the SNS Program also requests that each state prepare and participate in an exercise on receiving the SNS assets. This can be done once the SNS Program has approved a state’s SNS plan to receive the Stockpile assets. During the exercise, the SNS Program will send a Training, Education, and Demonstration (TED) package that is formulated to simulate a full 12-hour Push Package. The TED package will help validate local and state preparedness for receiving, distributing, and dispensing the Stockpile contents. The SNS Program has service consultants who consult states on the management and use of the Stockpile assets. They are available to assist state and local SNS coordinators with developing their plan and devising an SNS exercise. SUMMARY The SNS Program is designed to meet the overwhelming need that a community may face in a mass casualty event. The SNS Program delivers large quantities of medications and supplies; however, it relies on each state and local agency to provide the manpower needed to unpack, apportion, dispense, and account for the assets of the SNS. Health care providers need to be actively involved in the emergency preparedness planning, testing, and implementation phases of their community’s disaster plan to know how to take advantage of this significant resource. Before an event occurs, physicians, pharmacists, and nurses should contact their state SNS coordinator or state bioterrorism coordinator to identify their responsibilities during an event. These coordinators are available through the state health department or state emergency management office. The SNS Program service consultants also can assist with questions or with contacting state authorities. Contact information for SNS Program service consultants and additional Program information can be found at http://www.bt.cdc.gov under the Strategic National Stockpile. REFERENCE 1. Rotz LD, Khan AS, Lillibridge SR, Ostroff SM, Hughes JM. Public health assessment of potential biological terrorism agents. Emerg Infect Dis 2002;8:225-30. Volume 1, Number 3
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