Publisher’s Message: Carl Brewer was the president of Upp Technologies Inc., a Chicago-based supply chain management software company that developed an inventory management and distribution system used by 40% of the states for emergency management and distribution of the Strategic National Stockpile (SNS). With the management and delivery of personal protective equipment (PPE) being “breaking news,” Carl was asked to provide his insight on this highly debated topic to DomPrep’s readers.
Because of COVID-19, it is time to reevaluate preparedness and reconsider threats to the homeland. Good intentions and grand theories do not make good programs. Programs work best when they’re based on a detailed understanding of the problem begin solved and how they are implemented on the ground with solid funding commitments and realistic expectations.
As a short backdrop, in 1999, the National Pharmaceutical Stockpile was created to ensure the nation’s readiness against potential agents of bioterrorism like botulism, anthrax, smallpox, plague, viral hemorrhagic fevers, and tularemia. The mission was to assemble large quantities of essential medical supplies that could be delivered to states and communities during an emergency within 12 hours of the federal decision to use the stockpile.
The 9/11 terrorist attacks prompted federal legislation and directives to strengthen public health emergency readiness. In 2003, the National Pharmaceutical Stockpile was renamed the Strategic National Stockpile (SNS). Today, the SNS works with government and nongovernment partners to upgrade the ability to respond to a national public health emergency, ensuring that federal, state, and local agencies are ready to receive, stage, and distribute products.
The SNS has been deployed to multiple large-scale emergencies including floods, hurricanes, and influenza pandemics. It has also supported small-scale deployments for life-threatening infectious diseases like anthrax, smallpox, and botulism.
- 1999 – Stockpile established
- 2001 – World Trade Center & anthrax attacks
- 2005 – Hurricanes Katrina & Rita
- 2008 – Hurricanes Gustav & Ike
- 2009 – H1N1 pandemic influenza & North Dakota flooding
- 2010 – Hurricane Alex & North Dakota flooding
- 2012 – Hurricanes Isaac & Sandy
- 2014 – Botulism outbreak & Ebola
- 2015 – Ebola
- 2017 – Zika & Hurricanes Harvey, Irma & Maria
- 2019 – Hurricane Dorian
- 2020 – Novel coronavirus
The 2009 novel influenza A (H1N1) virus was the first large-scale, multi-territory deployment of the SNS. H1N1 had spread quickly across the United States and the world. Much like the events of today, this new H1N1 virus contained a unique combination of influenza genes not previously identified in animals or people. From 12 April 2009 to 10 April 2010, the Centers for Disease Control and Prevention (CDC) estimated there were 60.8 million cases (range: 43.3-89.3 million), 274,304 hospitalizations (range: 195,086-402,719), and 12,469 deaths (range: 8,868-18,306) in the United States due to the H1N1 virus.
On Saturday, 25 April 2009, under the rules of the International Health Regulations, the director-general of the World Health Organization (WHO) declared the 2009 H1N1 outbreak a public health emergency of international concern and recommended that countries intensify surveillance for unusual outbreaks of influenza-like illness and severe pneumonia.
Good intentions and grand theories do not make good programs. Programs work best when they’re based on a detailed understanding of the problem begin solved and how they are implemented on the ground with solid funding commitments and realistic expectations.
On 26 April 2009, the U.S. government determined that a public health emergency existed nationwide; CDC’s SNS began releasing 25% of the supplies in the stockpile that could be used to protect and treat influenza. This included 11 million regimens of antiviral drugs and personal protective equipment – including over 39 million respiratory protection devices (masks and respirators), gowns, gloves, and face shields – to states (allocations were based on each state’s population).
The 2009 H1N1 pandemic occurred against a backdrop of pandemic response planning at all levels of government, including years of developing, refining, and regularly exercising response plans at the international, federal, state, local, and community levels. This is critically important as regular exercises and response plans kept everyone communicating and ensuring that SNS products are properly grouped, rotated, and managed based on the exercise “threat response.” Equally as important is ensuring stock rotation as it manages products with shelf life, expiration dates, or certification requirements. In 2009 when funding was widely available, the state, local, and federal health agencies regularly practiced their response plans and included the local healthcare agencies, hospitals, and transportation service providers.
Ten Years Later – Response, Preparedness & Funding?
While the SNS reportedly holds some 16,000+ ventilators, of those deployed in March 2020, several states reported issues with ventilators not working, challenges with external battery packs, and ventilators with missing hoses to attach to the facilities’ oxygen supply. The various configurations in the SNS added to the confusion: the Zoll (Impact Instrument) Uni-Vent 754 kitted with one oxygen hose and one air hose; while the Covidien (Puritan Bennett) LP10 and Vyaire (CreFusion) LTV 1200 models do not come with oxygen hoses or air hoses.
Obviously, there was a lack of communication and expectation between federal and local levels that should have been addressed in response exercises by both parties. Similar challenges were reported with the N95 masks that were distributed – proper fitting and sizing, as well as certification validation are critical factors. Apportionment and distribution of limited supplies like the ventilators and masks became more of a political than a medical issue.
Based on the distribution challenges and readiness of PPE for the local healthcare professionals – the nation was not prepared. Reserves and replenishment pipelines were ill-prepared, ill-equipped, and responses delayed by politicians. This raises numerous questions, including:
- How can these response gaps be corrected going forward?
- What lessons were learned?
- Will there be a “hot wash” on the SNS once this pandemic is over?
In 2009, the successful response was based on federal funding, funding based on the threat of terrorism, but the enemy was not Anthrax. It was H1N1. Fortunately, the nation was prepared with enough PPE and antiviral drugs. With the reduced risk of terrorism, the funding has diminished at the state and local levels, leaving only the federal government. Undoubtedly, a reduced budget item based on risk – but now the nation has seen its new enemy.
As forecast by Bill Gates in 2015 and undoubtedly foreseen by leading epidemiologists, the new threat is a highly infectious virus. The nation as a whole has failed to invest in preparedness for an epidemic. It is now necessary to reinvent, reinvest, and renew the mission of the SNS. Relying on contractors will not ensure the readiness of medical protection, neither will relying on government employees to manage the rotation and inspection of medical supplies. Medical professionals must be incorporated and relied upon to forecast, define, and prepare the contents of a new revised SNS, one prepared for a highly infectious virus pandemic event.
Questions Need to Be Answered
The following images raise serious questions about the nation’s readiness and its ability to respond: when healthcare workers are televised begging for personal protection equipment (PPE) and seen wearing makeshift solutions so they can serve the health of citizens; when state governors are saber rattling with the president of the United States about ventilators; and when government officials are standing in front of medical professionals. These images spur questions like: Who is in charge? Who is responsible? Who should have ownership (federal, state, local, regional, or private)? Is the United States any better prepared than most 3rd world countries?
When the smoke clears and a “new normal” settles in, there needs to be a reassessment of SNS’s ownership, contents, maintenance, and distribution plans in order to better prepare for the next pandemic.