Medicines Stockpiled as Precaution

Somewhere in California and in seven other secret locations, millions of doses of antibiotics and other medications are stashed behind locked fences in warehouses near airports so they can be rushed within 12 hours to the scene of biological or chemical attacks.

These supplies, along with separate drug caches managed by private vendors, make up the National Pharmaceutical Stockpile that the government began forming two years ago to address the threat of terrorism on the home front.

Once out of sight and mind as an obscure civilian defense measure, the stockpile has become central to the nation’s preparedness after the attacks of Sept. 11 and the spread of anthrax through the mail.

But the stockpile program’s early history has been clouded by persistent misgivings about whether local and state officials would effectively deploy the supplies once they get them. The picture is somewhat better in California than elsewhere in the country, but overall, experts say many local governments have little or no experience with public health emergencies. Some have conducted “table top” rehearsals for bioterrorism scenarios, but few have mobilized for large-scale field exercises.

“The problem is . . . that the infrastructure and arrangements on the ground are not there,” said Thomas L. Milne, executive director of the 3,000-member National Assn. of County and City Health Officials. “There have to be people on the ground to administer the vaccine and dispense medications and [perform] all the related activity, such as record keeping and observation of side effects. . . . We just don’t give people pills and say, ‘Bye, bye.’ ”

The stockpile program was launched in 1999 with a projected cost of $500 million over five to seven years. For the last three years, however, Congress has provided only about $50 million annually.

Although the composition of the stockpile is secret, government officials confirm that it includes medications for anthrax, plague, tularemia and some other viruses and bacteria that could be used by terrorists. Officials say enough medication is on hand to treat 2 million people. With increased funding anticipated after the recent attacks, they hope to boost that to enough for 12 million people by December.

More training for local distribution of the stockpile is another pressing need, according to health professionals. Last month, the National Assn. of County and City Health Officials surveyed more than 500 health officials and found that only 20% had a comprehensive plan in place to deal with bioterrorism events--and 24% had no plan. Milne estimated that 13,000 health workers and more than $835 million a year are needed to strengthen the nation’s local bioterrorism response.

Major cities and states such as California tend to have the most resources and the strongest plans in place. But more field exercises are essential to get local officials ready for smooth distribution of the stockpile, said Steve Bice, director of the National Pharmaceutical Stockpile.

“If you have a plan, you must exercise it,” he said. “If you don’t exercise it, it’s not of particular use.”

California, New York, Michigan, Georgia and Alabama are leaders in the planning for emergency response, Bice said. “California is very advanced in planning and emergency response due to a long history of natural [disaster] events and takes seriously the issue of bioterrorism,” he said.

California has not conducted any large-scale field exercises for distributing the stockpile, but there has been extensive planning among federal, state and local agencies, said Dr. Kevin Reilly, the deputy director of the state Department of Health Services.

“We know how we’ll get it there and who on the other end we will communicate with,” he said.

In Los Angeles County, officials have built their own stockpile, mostly of antibiotics, and they plan to expand it so there are caches in several major areas.

“We are beefing up to try to take care of this county until the silver horses ride in with replacements,” said Virginia Hastings, director of Los Angeles County Emergency Medical Services.

On Thursday, county officials plan a drill that will involve a simulated request for aid from the federal stockpile but will not cover the logistics of receiving and distributing it. “We have been discussing the need in a subsequent exercise to go through the actual steps, including contacting the feds, without actually having it moved,” said Bob Garrott, assistant manager of the county office of emergency management.

Deployment of the stockpile is a major challenge, said Dr. Jonathan Fielding, director of the Los Angeles County Department of Health Services. “It is not only a question of distribution but of maintaining reasonable records and asking the right questions of people, especially those who might have side effects,” he said.

The county, despite its experience with natural disasters, should not feel overconfident because bioterrorism presents so many possible scenarios for attack, he added. “If we have a problem, I’m sure it will not go smoothly but we are better prepared than most to get the job done.”

If a biological attack were to take place, part of the national stockpile would be flown or trucked from the nearest warehouse to a designated local airport, then would be distributed by vans and a flatbed truck.

About 20% of the drugs in the national stockpile are held in 50-ton containers called Push packages. The packets are stored at eight locations, and officials plan to expand the number to 12. (One Push package arrived in New York City seven hours after the World Trade Center collapsed.)

Additional drugs managed by private pharmaceutical vendors can be delivered, if necessary, within 24 to 36 hours. About 15% of this privately managed stock, officials say, is on back order and not yet available.

The potential problems with distributing the stockpile were obvious a year and a half ago during a simulated attack in Denver that was part of the nation’s largest anti-terrorism drill.

Under the disaster scenario, officials pretended that plague had been released at the Denver Performing Arts Center. The script called for officials to deal with a mock epidemic that would kill up to 2,000 people within four days. When they summoned the stockpile, a simulated Push pack of medical supplies arrived promptly by plane.

Then came a procession of problems, according to a review of the drill conducted by the Johns Hopkins University Center for Biodefense Studies. Drug distribution was delayed for precious hours as individual pills had to be counted out and bagged. A distribution facility could only handle 140 people an hour in a city of 555,000. People took their antibiotics from a box with little oversight. There was infighting over the stockpile supplies managed by vendors after the disease spread to other cities and states.

Health officials were not accustomed to making speedy decisions, resulting in what Dr. Stephen Cantrell, associate director of emergency medicine at the Denver Health Medical Center, called “conference call hell--how many pills to give a patient, who should get the drugs . . . Who makes the decision?”

Bice, the stockpile chief, said the field exercise provided valuable lessons in coordination but exaggerated the difficulty in breaking down the stockpile into individual dosages.

Since the Denver exercise, the stockpile has acquired repackaging machines like those used by hardware chains to repackage nuts and bolts. “You pour the pills in the top and out comes a sealed Baggie with patient information,” said Bice. “They can handle 4,500 to 5,000 pills an hour.”

Dr. Greg Evans, director of the Center for the Study of Bioterrorism and Emergency Infections at St. Louis University, said that local governments remain unprepared for dealing with bioterrorism in general and the stockpile in particular. “If you are in a large metropolitan area, you will need 50 to 100 distribution sites,” he said. “If not, you will have people lined up for hours waiting for antibiotics.”

In late 1999, as the national Centers for Disease Control and Prevention began building its pharmaceutical stockpile, the General Accounting Office concluded that chemical and biological medical supplies stockpiled by other federal agencies were poorly managed and could harm the country’s ability to respond effectively to an attack. In comparing the supplies to written inventories, auditors found overages, shortages, expired drugs and inadequate security.

A follow-up report this spring concluded internal controls and security were markedly improved but needed more work. In September, the GAO reported that each agency was replacing inventory systems with improved ones providing greater assurance that stockpiles are ready when needed.

In light of the Sept. 11 attacks, the government should commission an independent audit of the stockpile, said Dr. Tara O’Toole, deputy director of Johns Hopkins University’s Center for Civilian Biodefense Studies. “I think what the public wants is independent reassurance that smart people are paying attention to the stockpile, that it’s not going to molder away, that it’s big enough and available,” she said.

And even in cities with substantial experience in handling major medical emergencies, more practice is needed to properly deploy the supplies, said Dr. John Brown, medical director of San Francisco County’s Emergency Medical Services. “We need more drills and drills of the entire system at the same time,” he said.

Drilling, he said, “is the difference between having a plan and an operation. We have a plan.”