While the mission of the Strategic National Stockpile (SNS) has not changed since Congress established this national repository of emergency medicines and supplies, public health events in the United States during the past 20 years have led to a dramatic expansion of the scope of the stockpile’s capabilities. Originally focused on protecting Americans from bioterrorist threats surrounding the year 2000, or Y2K, the stockpile has grown and evolved to a greater than $8 billion enterprise that contains more than just medical countermeasures (MCMs) for biological and chemical threats. The mission authorized is broad enough to encompass virtually any threat to national health security, and the progress SNS has made operationally lends it to encompassing a continually evolving landscape of risks that might be mitigated.
Today’s stockpile, now managed by the U.S. Department of Health and Human Services’ (HHS) Assistant Secretary for Preparedness and Response (ASPR), is poised to respond to a wide variety of threats – including both long characterized and newly emerging bacterial and viral diseases, pandemic influenza, and natural disasters, as well as chemical, biological, radiological, and nuclear incidents. When a public health emergency is severe enough to cause readily available MCMs to run out, the stockpile can deliver medicines and supplies to supplement response efforts. In fact, as the sole source for several important licensed products, the stockpile often steps in immediately. Even if the needed products are not currently held in house, stockpile experts have purchasing power to get what is needed to protect Americans. The mission is the same: to provide the right material at the right place at the right time to secure the nation’s health. Flexibility and scalability are the only ways to ensure success in the ever-evolving world of emergency preparedness and response.
Incorporating Natural Disaster Preparedness and Response
While stockpile experts were rapidly building the SNS formulary in its early years, HHS assigned the program with a new project in 2004 to develop “Public Health Contingency Stations,” which were the early versions for the modern-day Federal Medical Station (FMS). The goal was to create 250-bed modular units with the ability to support quarantine, light treatment, or triage needs of an affected area. Today’s FMS serves as a non-emergency medical center set up during a natural disaster to care for displaced persons with special health needs – including those with chronic health conditions, limited mobility, or common mental health issues. These are people who have needs that cannot be met in a shelter for the general population during an incident.
Just one year following the initiation of this project, the Gulf Coast was ravished when Hurricanes Katrina and Rita made landfall within just a few weeks of each other. This was the first time the SNS was called upon to assist with a natural disaster. Initially, the stockpile program deployed a 12-hour Push Package, a broad spectrum of supplies that could meet hurricane disaster needs. This was the second time the SNS had deployed a push package; the first one deployed to New York City in response to the events of 9/11.
As the hurricane response developed and more was known about the magnitude of the disaster, shipments of managed inventory were sent, and the stockpile purchased supplies that were needed but not part of the SNS formulary. Rapid purchasing power is a cornerstone of today’s stockpile operation, but this was a novel action at the time. In addition to the deployment of pharmaceuticals and medical supplies sent for hurricane victims, the SNS also deployed 16 FMSs, each which could support 250 patients for up to three days before resupply was needed. Thirty-three SNS experts deployed with the product to assist on the ground in the Gulf Coast jurisdictions.
Every response brings lessons learned to those involved. These hurricane responses revealed the importance of coordination and communication among federal, state, and local partners, especially to connect people to the right resources. These responses also highlighted the issue of shortages of chronic care medications such as blood pressure medicine following a natural disaster. Hurricanes Rita and Katrina solidified the SNS’s natural disaster response capability and set the stage for future responses – including Red River flooding, Superstorm Sandy, and Hurricane Maria. Lessons learned often lead to innovation in design and new technology that improves capability. For example, just recently under ASPR’s leadership, the SNS was able to work with other ASPR organizations to add a capability to deploy a limited amount of dialysis equipment to the site of an emergency with an FMS or as a standalone set.
Incorporating Influenza Pandemic Response Capabilities
In 2003, the SNS added 400,000 doses of antiviral drugs to its formulary in preparation for a pandemic influenza. This was the first procurement for the formulary beyond the original mission focused on terrorist incidents and represented an entirely new and different scope. When the 2009 H1N1 influenza pandemic began affecting populations worldwide, the SNS was prepared. This response proved the biggest deployment and longest activation in the stockpile’s history. No response since has exceeded the scope and magnitude of the 2009 H1N1 response.
The federal response to H1N1 was massive. The stockpile alone deployed 12.5 million regimens of antiviral drugs, 19.6 million pieces of personal protective equipment (PPE), 85.1 million N95 respirators, and 2,129 doses of IV peramivir. The SNS delivered medicines and supplies to all 50 states, four directly funded localities, and eight territories and island jurisdictions in the Caribbean and the Pacific Ocean. The SNS also assisted with efforts to attempt to contain this disease threat by working with other governments to provide access to antiviral drugs.
Just like other response efforts, H1N1 was a learning experience for the SNS. First, the program proved that a nationwide full-scale deployment was possible, and it worked. Other lessons learned included realizing the importance of communicating inventory and shipping data and that commercial supply chain visibility was paramount to good decision making. The federal response to the 2009 H1N1 pandemic marked the beginning of the stockpile’s work to establish lasting and trusting planning relationships with commercial supply chain partners. This further served as a lesson to the world in planning for stockpiling globally. The 2009 H1N1 response was the largest known response of a national stock of drugs and medical material, and it was successful.
Planning for Unknown Threats
In the next five years, the international public health community faced two specific emerging diseases that threatened to spread between countries and continents, which was not unrealistic considering the ease of air travel over great distances. Ebola and Zika both presented challenges to public health because neither had pharmaceuticals or therapies to effectively cure the diseases, and the SNS held little to combat either disease.
For Ebola, the SNS strengthened its connections with commercial supply chain partners to help alleviate shortages of PPE needed by healthcare facilities in the United States. The SNS accumulated a limited stock of PPE, but primarily served as the link between the commercial supply chain and public health to inform and prioritize orders of PPE by facilities most likely to receive an Ebola-infected patient. SNS experts realized the value of supply chain integration in an emergency response and tested its capabilities to support MCM requirements even when product is not available in SNS holdings. By working directly with commercial partners, SNS experts help inform the distribution process to direct supplies to those healthcare facilities most in need rather than deploying the limited stock from SNS inventory.
Zika also challenged stockpile operations by requiring preventative products and services that were not in SNS inventory. Testing again its capability to respond with items not held by the SNS, personnel procured and assembled products for Zika Prevention Kits, which contained items like bug sprays, mosquito dunks, mosquito nets, and more. SNS staff also served as liaisons for the kitting and distribution process as well as for vector control services. Broad SNS authority to provide for public health enabled innovative solutions to fight Zika that were beyond pharmaceuticals. A clear lesson in the response to Zika was that the SNS could rapidly acquire non-medical countermeasures to limit disease spread. This response further emphasized to SNS that the importance of stakeholder and community engagement to reach buy-in could not be underestimated.
Adapting to New Emergency Response Landscape
The evolving world of public health emergency response is not unique to the stockpile, but the variety of U.S. public health emergencies in the last 15 years have shaped the SNS response capability and allowed the organization to mature its operations. Perhaps the most important aspect of these formative years was the connection the SNS made with its commercial supply chain partners.
To truly engage all elements of the medical supply chain in the United States, the SNS took the unusual step of inviting the private sector to participate in tabletop exercises to explore supply and demand challenges during public health emergencies. Representatives from a variety of suppliers, many of whom had no previous relationship with the SNS, attended these exercises. Notably, the Health Industry Distributors Association – a key SNS partner – was instrumental in bringing its member organizations to the table. This effort has since expanded into a second round of exercises to reach even more commercial sector suppliers. Based on feedback from participants, the SNS has helped sensitize this sector to public health challenges, such as the impact of a surge in demand for products, that must be addressed before an emergency occurs.
Solidifying these relationships only strengthens the work of both the private sector and government and allows for better preparation against threats that can harm communities nationwide. Today, ongoing collaboration between government and private industry allows the integration of the SNS and commercial supply chain response planning and capabilities. The benefit of this public-private collaboration is that it simplifies the emergency response for greater efficiency, can potentially reduce stockpiling requirements for SNS, and has the potential to strengthen commercial capacity and resilience. All of these aspects mean that more partners are involved and dedicated to ensuring that all Americans are protected from public health threats whenever and however they arise.
This article is the second of a three-part series:
Part 1 (published in October 2019): The Early Years: Shaping a National Stockpile for Preparedness
Part 3 (published in December 2019): Looking Ahead – Future of the Strategic National Stockpile
Greg Burel is director of the Strategic National Stockpile, managed by the Department of Health and Human Services’ Assistant Secretary for Preparedness and Response. As head of the nation’s largest stockpile of medicines and supplies available for emergency use, he is a leading expert on medical supply chain management in the United States. With more than 35 years of civil service, he has risen through the ranks of the federal government, beginning his career at the Internal Revenue Service and serving in leadership roles in both the General Services Administration and the Federal Emergency Management Agency. In 2006, he assumed the helm of Strategic National Stockpile operations. He was awarded the Samuel J. Heyman Service to America Medal for Management Excellence and selected as a National Academy of Public Administration fellow in 2016.