Section 2: Evaluation of the National Emergency Stockpile System (NESS) – Background

2. Background and context

This section provides a description of the mandate and operation of the National Emergency Stockpile System (NESS) program. It presents a brief overview of its 60-year history and provides a description of the deployment of NESS supplies over the past 25 years.

2.1 What is the NESS?

The Public Health Agency of Canada is the lead federal agency mandated to manage public health emergencies and regional coordination of federal health emergency activities. It works with international partners, provinces and territories, and other federal partners to monitor international and domestic public health threats and to mobilize a pan-Canadian response to public health events of national or international concern (Appendix C provides a broad overview of the roles of various domestic and international authorities and stakeholders in emergency preparedness and response).

The Public Health Agency maintains the NESS to provide emergency supplies to provinces and territories when requested. In the event of a local emergency that overwhelms available municipal resources, the municipality contacts the provincial/territorial emergency management authorities for additional resources. When provinces and territories cannot supply the required resources, they can request surge resources from the NESS. Release of equipment or supplies is coordinated through the provincial/territorial Health or Social Services Director.

The system consists of a series of warehouses and pre-positioned sites. Precise locations of any of the warehouses/sites are not made public for security reasons.

• There are a total of 11 federal warehouses leased by the Public Health Agency: two main depots in the National Capital Region (Ottawa) and nine warehouses located across Canada. There are no federal warehouses located in the territories. The Public Health Agency has contracts in place for both custodians and security for all 11 federal warehouses.
• There are approximately 1,300 pre-positioned sites located across Canada. Each province and territory determines the locations of the pre-positioned materials and is typically responsible for that warehousing space (including leasing costs and security). The Public Health Agency owns the assets in the pre-positioned sites.
• Supplies are designed and packaged for long term storage; date-sensitive supplies remain at the Ottawa depots.
• The program indicated that 66% of supplies deployed are released from the Ottawa depots, 12% from the other federal warehouses located in the provinces, and 22% from pre-positioned sites.

The NESS contains a variety of assets. The program categorizes its assets as follows (see Appendix D for a detailed list of components):

• medical equipment and supplies (individual items such as ventilators, personal protective equipment such as masks and gloves, operating room tables, stretchers, wound dressings, bandages, etc.)
• pharmaceuticals (individual items such as antiviral agents; antibiotics; chemical, biological and radio-nuclear [CBRN] antidotes, etc.)
• social service supplies (individual items such as generators, cots, blankets, flashlights, etc.)
• modules, units or "kits" (compilations of items such as Casualty Collection Units, mini-clinics, reception centre kits, etc.).

These supplies have been deployed domestically and internationally in response to a variety of public health events and other emergencies, and in preparation for mass gatherings. Responses have been medical and/or social service in nature.

The program also indicated that the NESS warehouses medical supplies and/or pharmaceuticals for other government departments or agencies, including: the Canadian Food Inspection Agency, the Department of National Defence and Health Canada.

The NESS program offers some training activities for end users of its supplies. In the past, it offered training on the set-up and maintenance of each of the kits stored in the warehouses, including emergency hospitals. Currently, the NESS program offers training on the set-up of mini-clinics.

Example of NESS Kit

The NESS program is one of the programs within the Office of Emergency Response Services (OERS), Centre for Emergency Preparedness and Response, Emergency Management and Corporate Affairs Branch within the Public Health Agency. It is listed in the Public Health Agency's 2010-11 Program Activity Architecture (PAA) under program sub-activity 1.6.3, entitled "Emergency Stockpile."

The current value of NESS supplies is estimated by the program to be $300 million. Of that amount, the value of pharmaceuticals in the stockpile is estimated by the program to be $112 million.

Approximate annual program expenditures were:

• In 2009-10 the total program expenditure was approximately $5.5 million, including approximately $4 million for operations and approximately $1.5 million for salaries.
• The $4 million in operating dollars included acquisition of new or replacement equipment and supplies, staff travel (for example, to set up and train on kits such as mini-clinics), contracts (for example, for custodians, security, etc.) and transportation of equipment and supplies for deployments, as required.
• In addition, the leasing of warehouse space for 2010-11 is estimated at $7.7 million annually.

In 2009-10, there were 27 staff assigned to the NESS program:

• The staff complement included a Director, a Chief, an Assistant Manager, 3 inventory control staff, a pharmacist and 22 warehouse staff (roles include store person, logistics officer, carpenter, traffic supervisor and forklift operator).
• The program has indicated that a biomedical technician will also be hired.
• At the time of this report, the program's Director and Chief had recently been appointed to their positions; on the other hand, many of the warehouse staff had worked there for 10 years or more.

2.2 The history of the NESS program

Preparing for the worst

The NESS program was created in the 1950s as part of a civil defence plan against a potential nuclear attack arising from the Cold War that would threaten the infrastructure of major Canadian cities. In response to this perceived threat, the NESS program was established to enable a sustainable medical and social services response to a nuclear disaster. The authority for the then Minister of National Health and Welfare to stockpile supplies is based on a Cabinet decision on January 11, 1952.^{[Link to footnote 2]}

The initial, centrally managed and stored stockpile consisted of a variety of medical and social service provisions (1950s and 1960s):

• Medical supplies consisted primarily of Casualty Collecting Units (CCUs) designed to provide front-line response at the rescue site; Advanced Treatment Centres (ATCs) designed to support triage and early life-sustaining field treatment; and 200-bed, fully equipped emergency hospitals. The emergency hospital concept was intended to provide life-saving surgical and post-operative care and to supplement hospital care capacity in the affected area of a disaster.
• The social service elements of the NESS program consisted essentially of mobile feeding units, reception centre kits, and cots and blankets. These supplies were intended to support basic needs for emergency lodging, feeding and clothing, as well as personal services, such as registration/inquiry services and rehabilitation planning.

Given the social, economic and political environment during the Cold War period, the concept of a national stockpile was well founded. There were significant lag times for manufacturing goods and limited transportation options; in contrast, warehousing costs were relatively inexpensive. Importantly, at that time, the health care system at the local level had more limited capacity to respond to a large-scale emergency than it does today.

Over time, the threat of a nuclear attack decreased, and the scope of the NESS program expanded to include the capacity to respond to technological and natural disasters. In 1964, Cabinet decided to relocate some of the NESS supplies to a number of regional federal depots and to pre-position other supplies within each of the provinces and territories.

The authority for the provinces and territories to use these supplies during peacetime was based on a June 7, 1965 Cabinet decision.[Link to footnote 3] The NESS program was officially mandated to act in a surge capacity for provinces and territories in peacetime disasters. Memoranda of Understanding with the provinces and territories were developed in the mid-sixties to facilitate the transfer of Crown assets, stipulating that provinces and territories were responsible for the storage of supplies in their jurisdictions. The stockpile was not a first-response tool; its purpose was to assist the response of provinces and territories to a natural or man-made disaster or other medical emergency that required additional resources.

Since 2001 the majority of the NESS purchases have been pharmaceuticals. The tragic events of September 11, 2001 initiated an important shift in focus in emergency preparedness planning around the world. The threat of a bioterrorist attack triggered a gradual expansion of the NESS stockpile, with the accumulation of a unique set of chemical, biological, and radio-nuclear (CBRN) countermeasures (such as vaccines or antidotes for smallpox, botulism and anthrax) to deal with this new threat.

In 2004, following the Severe Acute Respiratory Syndrome (SARS) outbreak, the Public Health Agency was established to provide a focal point for federal leadership in managing public health emergencies and improved collaboration within and among jurisdictions. Still part of the federal Health Portfolio, the NESS assets were transferred from Health Canada to the newly created Public Health Agency.

The SARS outbreak triggered preparations for a new global threat, pandemic influenza, with the subsequent initiation of substantial NESS stockpiling of pandemic response supplies. This surge supply included antiviral agents, antibiotics specific to pandemic response, syringes, ventilators and related oxygen supply equipment, personal protective equipment (masks, face shields, gloves), and other supplies such as gowns, disposable sheets, pillows, needles, syringes and body bags.

In 2011, the public health threats in our current environment are complex: natural disasters, new emerging pathogens, and accidents or terrorism acts involving explosives, chemicals, biological threats or radioactive substances. These events potentially present a risk to Canadians' health and well-being.

At the same time, over the last 60 years there have been significant changes in the context in Canada:

• advances in technology have increased the ability to identify and adequately respond to possible threats and to improve safety and public health in general
• pharmaceutical products and equipment have also evolved and become progressively complex to manage
• the network of community hospitals has expanded and the health care system's capacity to respond to various threats has improved
• the development of critical infrastructure makes prompt transportation possible, offers more options for acquisition of supplies, and enhances emergency response capacity at local, provincial and territorial levels.

Much dialogue on "modernization" of the NESS

Over the past three decades, numerous reviews/audits and research reports have focused on the so-called "modernization" of the NESS program, including the following from the past few years:

• 2004 National Emergencies: Canada's Fragile Front Lines, Report of the Standing Senate Committee on National Security and Defence
• 2005 Report of the Auditor General of Canada, Chapter 2, National Security in Canada
• 2006 National Emergency Stockpile System Strategic Review, Public Health Agency of Canada
• 2008 Emergency Preparedness in Canada, Report of the Standing Senate Committee on National Security and Defence
• 2010 Audit of Emergency Preparedness and Response, Public Heath Agency of Canada.

The majority of findings and recommendations from these previous reports have been consistent, as reflected in the latest report, the 2010 Audit of Emergency Preparedness and Response:

The mandate of the National Emergency Stockpile System (NESS) requires renewal in order to more appropriately reflect its current emergency response role. In addition, program management attention is required to address issues related to NESS acquisition practices, supply and equipment maintenance processes, inventory valuation, control and record keeping systems and processes, inventory obsolescence processes and information management capabilities.^{[Link to footnote 4]}

While each report indicated that minimal progress had been made to date to address previous recommendations, it should be noted that the Centre for Emergency Preparedness and Response is currently actively responding to the recommendations outlined in the 2010 Audit report. For example, to support evidence-based decision making, the establishment of a Pharmaceutical and Therapeutic Committee has recently been approved and a Material Supply and Equipment Committee is under development.

2.3 Deployment of NESS supplies

Limitations of data

As mentioned in the 2010 Audit on Emergency Preparedness and Response, the Public Health Agency does not have an electronic inventory system for the NESS program. While the development of an electronic inventory system has been initiated, at this time it is not possible to know how many items have been in stock since the inception of the program in 1952 to the present date. It is also not possible to estimate the percentage of supplies in the stockpile that have been deployed compared with those that have not been deployed over the program's history.

While international data is available from 1960 to 2010, domestic deployment information is only available for the past 25 years (1985 to 2010). Deployment information is also subject to recording error, which could affect how supplies were classified (medical, social or pharmaceutical) or how an event was classified (technological disaster versus supply disruption i.e. NESS providing supplies to other parties to respond).

There were also significant gaps in the international data available. When it has been unclear, the data has been coded as "unknown":

• It appears that, most often, supplies were provided through the Canadian International Development Agency (CIDA). Almost as often, there was no data available about to which organization the supplies were issued.
• The nature of the international event for which supplies were deployed is often not recorded, although reasonable assumptions could be made for some entries. For example, a deployment was sent to Turkey in 2003 for an unrecorded reason. A large earthquake occurred in Turkey during the same time frame. One cannot attribute the deployment to a geological event, however, as the reason for the request was not recorded.

With these limitations in mind, we can offer the following depiction of how the NESS stockpile has been deployed over the past 25 years.

Domestic deployment pattern

Over the past century, there have been about 1,000 Canadian disasters. These events have been primarily meteorological/hydrological (floods, wildfires, tornadoes, etc.), technological (industrial fires) and biological (pandemic influenza) in nature. There have been far fewer cases of geological (earthquake) or conflict-related events in Canada.^{[Link to footnote 5]}

Figure 1: Domestic Deployment by Hazard, 1985 to 2010 (n=128)

According to records kept by the Agency, the NESS program has been deployed 128 times in the past 25 years (1985 to 2010) to respond to a domestic event as a result of a hazard:

• Just over four in ten deployments (43%) have been in response to meteorological or hydrological events. The Red River floods in Manitoba in the late 1990s or in Saskatchewan in 2006, and the response to the ice storm in Ontario and Quebec in 1998 are examples of these types of deployments.
• Technological deployments (13%) have included responses to industrial fires (1990), power outages (2003) and the Swiss Air crash off the coast of Nova Scotia (1998).
• Deployments to biological events (13%) have primarily been responses to the SARS (2003) and H1N1 (2009) outbreaks.
• There have also been deployments during times of conflict such as during the Oka crisis (1990) and the "9-11" attacks that stranded airline passengers in eastern Canada (2001).
• Deployments of the stockpile have also included a surge capacity role for mass gatherings (7%). The use of the mini-clinic at the 2010 Winter Olympic Games in Vancouver is a recent example.
• Supply disruption deployments are primarily to support other organizations when their own supplies have been depleted due to an event or a disruption in the supply chain. For example, Oseltamivir (an antiviral) was issued as replacement stock to the Canadian Food Inspection Agency after an outbreak of avian flu was detected at a farm in 2004. Similarly, field dressings were shipped to the Department of National Defence as a replacement stock in 2007.

Figure 2: Types of Stock Deployed Domestically, 1985 to 2010 (n=335)

Over the last 25 years, just under half the number of supplies deployed to respond to domestic events have been social service supplies (46%). Medical supplies (44%) have been deployed slightly less often. Pharmaceuticals (6%) or units/kits, such as the trauma or the casualty collecting unit (4%), have been deployed far less often.

Closer scrutiny of the items contained in these categories reveal that beds, stretchers, blankets and reception kits/cards accounted for approximately two-thirds of all items deployed.

International deployment pattern

Figure 3: International NESS Deployment by Hazard, 1985 to 2010 (n=22)

While there is no specified mandate to provide supplies from the stockpile to assist in international public health events, over the past 25 years, the stockpile has been deployed internationally at least 22 times. Whereas domestically we saw a greater need for social service supplies in response to natural disasters, internationally there was a greater need for health supplies in response to conflicts or geological events. Deployments have included support for the response to the tsunami in Southeast Asia (2005) and after Hurricane Katrina in the United States (2005) and, more recently, the earthquake that occurred in Haiti in 2009 (supplies were distributed in 2010). These types of events have been catastrophic in nature, with high morbidity and injury rates.

Figure 4: Types of Stock Deployed Internationally, 1985 to 2010 (n=73)

Medical equipment and supplies represented the largest proportion of the supplies deployed internationally (44%), followed closely by pharmaceuticals (37%). A smaller proportion was classified as social service supplies (18%). Only one kit, a mobile feeding unit, was ever deployed (1%).

As in the case of domestic responses, one deployment could include social service and medical supplies as well as pharmaceuticals. For example, after the tsunami in 2005 in Southeast Asia, generators (coded as medical equipment), water bladders (coded as social services) and many pharmaceuticals, such as antibiotics and acetaminophen, were provided to CIDA for its response.