The Strategic National Stockpile (SNS) was founded by the CDC in 1999. It is a multibillion-dollar inventory of drugs, antidotes, vaccines, and other medical supplies meant to be easily deployable to any US state that needs additional medical assistance. Managed by the CDC’s Division of Strategic National Stockpile (DSNS). (pg1)
Shortages and supply chain gaps result from a “mismatch on supply and demand” (pg8)
Areas of Supply Chain Risk
- Many raw materials for medical supplies come from limited geographic regions. For example, 90% of latex for sterile gloves comes from Malaysia. (pg10)
- Supply Consolidation (fewer providers of raw materials leads to a higher chance of chain disruption).
- Shortages ripple down the supply chain
- Demand for alternatives increases
Supply Shortage ⇒ Product Shortage ⇒ Alternative Shortage
There has been a rise in pressure to keep inventory costs low, leading to faster turnovers and leaner inventories across the supply chain. Cheaper, but has very little flexibility in times of demand surge. Demand must be predictable and steady to work. (pg 11)
Phantom Demand: occurs “when facilities or distributors, predicting an impending shortage, order more… than they may actually need, and then cancel orders as soon as demand is met”. (pg 12)
During the 2009 H1N1 outbreak, there were double and triple orders on “slow” items –syringes, bandages– that took longer to arrive than the vaccines. (pg12)
During surges, lead times may also last longer than the demand for the item (e.g. a company ordering raw materials which only arrive after the demand curve has dropped). (pg 12)
“It took us almost 18 months to recover from our H1N1 pandemic [surge]… That was just H1N1, so we can only imagine what would happen in the event of something else… The system is not resilient.”Brad Noé, 2018: Global Technical Resources Manager for Becton, Dickinson and Company: pg 13.
The PSCN (Pandemic Supply Chain Network), formed by the CDC, WHO, UNICEF, various NGOs, and multiple medical supply companies, aims to set up advance purchase agreements to expedite supply delivery during a pandemic. (pg 13)
Addressing Supply Chain Gaps
- Public–Private Coordination (pg 14-16)
- Coordination between government (e.g. the DSNS) and private companies
- Internal supply chain redistribution (Walgreens moved supplies from around the country to Texas in the aftermath of Hurricane Harvey).
- Agreements for temporary changes in regulation during emergencies (e.g having more than the allowed amount of an emergency drug refill, for example 30 day’s worth instead of 7; or distributing vaccines to those without prescriptions).
- Communicate and share data to avoid regional supply chain imbalances, increase preparation for emergencies
- Characterize shortages and their causes
- International Coordination (pg 17-19)
- The PSCN connects distributors and manufacturers, along with NGOs. Arranges long-term advance purchasing agreements between partners on 62 essential products.
- The United Nations Global Marketplace (UNGM) has the first chance to buy the pre-vetted products through the PSCN, and then nations can buy the products from the UNGM.
- Trade policies affect the ability to acquire medical equipment, such as PPE from China or surgical instruments from Mexico and Pakistan.
- Importance of Communication (pg 18-19)
- Communication between companies and the government for emergency planning
- Communication between levels of government (those speaking with companies and lawmakers, trade policy makers).
“The right thing at the right place at the right time”.DSNS Director Greg Burel, 2018; on the purpose of the SNS: pg 21.
Many considerations are required when planing the deployment of SNS supplies, including what supplies are needed, where the supplies can be staged (so as to be close to the disaster area for deployment but far enough away to be safe), and how to overcome obstacles in transportation. (pg 22)
To deploy (especially in large events), the SNS uses existing distribution pathways (thus interacting with the medical distribution system), either becoming a normal distributor or a specialty distributor when necessary. (pg 23)
The SNS has become more than a pile of supplies, but also a strategy. The SNS interacts with the entire supply chain, making sure that raw materials are accessible by manufacturers, and that products move downstream properly, all the way to their final users. (pg 23)
The SNS has the ability to operate as an intermediary between public and private sectors, without some of the legal or economic constraints either sector may have normally. (pg 23)
- Communication, guidance and planning are essential:
- There must be a proper distribution system arranged between state and local public health agencies. (pg 24)
- There must be guidelines to help prevent shortages (i.e. what are acceptable alternatives for a drug that isn’t available? What are the guidelines for making necessary treatments of children when the required drug is only approved for adults?). (pg 26)
- Liability for hospitals must be managed in during times of shortages
“… identify key audiences to receive preparedness information in advance of an emergency and craft appropriate information for each such audience”DSNS Director Greg Burel, 2018; one of the goals of the SNS: pg 31.
Audiences include Public Health Officials, Hospital Administration, Clinicians and Emergency Responders (pg 32).
- To effectively use the medical countermeasures (MCMs) included in the SNS, clinicians need to receive quality, detailed guidance (pg 33).
- For example, many MCMs for CRBN events (like anthrax) have never been tested on humans, per the FDA’s Animal Rule
- Information should come from a trusted and exclusive source, so as to avoid conflicting or false guidance
- Clinicians should be aware of SNS capabilities (pg 35)
- E.g. that CHEMPACKs exist, but for security reasons should only receive “just-in-time” training about their contents and locations
- Guidance should be concise, brief and focused
- Depending on the context, the SNS may be the first response, but it should never be used in the case of general supply shortages. (pg 38)
- There should be open lines of communication across the medical supply chain with the SNS, as the role of the SNS is constantly expanding/changing.
“We will be judged ultimately by how well we do with respect to the vulnerable populations.”Irwin Redlener, 2018: pg 40.
- Some summary points: (pg 40)
- “The SNS is well run and effective, but increasingly squeezed: Its mission has expanded, its supply chain has grown leaner, and its budget has not increased to address either challenge.”
- “Underfunded and/or disorganized state and local public health departments jeopardize the “last mile” of the SNS mission.”
- “National health security depends on the medical supply chain.”
- “Communicating with partners across the supply chain, and with policy makers who influence the supply chain, is a critical function of the SNS.”
- “Strategic issues underlie tactical challenges faced by the SNS.”
- “Research toward developing pediatric medical countermeasures is sorely lacking.”
- “Preparedness can be improved by monitoring and studying disaster re-sponses and their aftermath.”
Every state holds a cache of antivirals, lawmakers need to be informed on whether they should prioritize reinvestment in cache upkeep (pg 40).
Tighter SNS Budget ⇒ Greater reliance on commercial supply chains ⇒ Leaner, Less ability to surge
Impact of the Global Medical Supply Chain on SNS Operations and Communications (Workshop), et al. Impact of the Global Medical Supply Chain on SNS Operations and Communications: Proceedings of a Workshop. 2018.