News Release

Community storage of anthrax-preventing antibiotics should be determined by state

Peer-Reviewed Publication

National Academies of Sciences, Engineering, and Medicine

WASHINGTON ― As part of preparations for a possible large-scale anthrax attack, public health officials on the state and local levels should determine where and how anthrax-preventing antibiotics should be stored in their communities, says a new report from the Institute of Medicine. The report recommends that state, local, and tribal health officials work with the federal government to assess the benefits and costs of strategies that preposition antibiotics close to or in the hands of people who will need quick access to them should an attack occur. These locations include local stockpiles, workplace caches, or possibly homes. However, the report discourages broad use of a home storage strategy for the general population due to possible antibiotic misuse and higher costs.

"Delivering antibiotics effectively following an anthrax attack is a tremendous public health challenge," said Robert Bass, chair of the committee that wrote the report and executive director, Maryland Institute for Emergency Medical Services Systems. "The Strategic National Stockpile has ample supplies of the antibiotics. The issue is not whether inventory is adequate but how to get the medication into people's hands soon enough to be effective. Because needs and capabilities vary across the country, state and local governments will have to examine which strategies would work best for them should an attack occur."

Antibiotics are most effective at preventing anthrax if taken before symptoms begin to occur -- a timeframe likely to be four days or longer, according to the report. Current federal, state, and local plans for dispensing antibiotics rely heavily on post-attack delivery from state stockpiles or the Centers for Disease Control and Prevention's Strategic National Stockpile, a national repository of medicine and medical supplies that can be deployed rapidly. Antibiotics from these stockpiles are dispensed to the public primarily at points of distribution (PODs) located throughout a region. The goal is to get antibiotics to all individuals in need within 48 hours of a decision to dispense. To complement these current plans, each jurisdiction should assess the benefits and costs of different strategies for storing antibiotics locally and determine which ones would be most appropriate for their communities, the report concludes.

For areas that are at higher risk for an attack and have limited dispensing capability through the current POD system, the report recommends considering "prepositioning strategies" to keep medicine stockpiled near where people work and live. These strategies may help individuals receive antibiotics more quickly. However, prepositioning strategies will cost more than centralized distribution systems, and once implemented, these plans may be difficult to alter. In areas where the risk of an attack is low and/or dispensing capability is sufficient, existing PODs likely already fulfill the needs of a community and prepositioning strategies may offer little additional value, the report says.

The report also considers predispensing antibiotics, a form of prepositioning in which the intended end-users are given possession of the antibiotics prior to an attack. This could take the form of personal stockpiling where individuals obtain antibiotics pre-event from a standard prescription or emergency MedKits with special packaging that should only be opened in case of an attack. The report discourages predispensing for the general public because it is unlikely to be cost-effective and carries significant risks, including a possible high rate of inappropriate antibiotic use. Examples of inappropriate use include taking the antibiotics to treat an unrelated condition or when it is not needed, such as in response to a false alarm or distant anthrax attack. The report found limited evidence to suggest that a MedKit approved by the FDA would lower that risk. A MedKit would also be likely to cost significantly more than a standard antibiotic prescription. However, the report finds some cases in which targeted personal stockpiles might be helpful. For example, communities may consider predispensing for some first responders, health care providers, and other workers who support critical infrastructure. Predispensing may also be appropriate for individuals who cannot travel to PODs to receive antibiotics because of a medical condition.

In addition, the report provides guidance for state, local, and tribal policymakers and public health authorities on how to assess the benefits of prepositioning strategies. Factors to consider include the risk of an anthrax attack; the ability to detect an attack quickly; an assessment of the current dispensing system; and an evaluation of the costs, risks, and benefits of prepositioning strategies like local stockpiling.

The report recommends that the government coordinate with private-sector organi­zations to alleviate the burden on the PODs and better reach every person who requires antibiotics. Although the responsibility for responding to an anthrax attack traditionally lies with the public sector, private-sector organizations have relevant expertise and resources that could be useful in case of an attack. These organizations may be interested in playing a greater role in distributing and dispensing antibiotics to ensure business continuity and help protect employees and their families.

The report does not address the priority of stockpiling anthrax-preventing antibiotics relative to other disaster preparedness activities, such as planning for other kinds of terrorist attacks, natural disasters, and infectious diseases.


The study was sponsored by the U.S. Department of Health and Human Services. Established in 1970 under the charter of the National Academy of Sciences, the Institute of Medicine provides independent, objective, evidence-based advice to policymakers, health professionals, the private sector, and the public. The National Academy of Sciences, National Academy of Engineering, Institute of Medicine, and National Research Council make up the National Academies. For more information, visit or A committee roster follows.


Jennifer Walsh, Media Relations Officer

Lorin Hancock, Media Relations Associate

Luwam Yeibio, Media Relations Assistant

Office of News and Public Information

202-334-2138; e-mail

Pre-publication copies of Prepositioning Antibiotics for Anthrax are available from the National Academies Press; tel. 202-334-3313 or 1-800-624-6242 or on the Internet at Reporters may obtain a copy from the Office of News and Public Information (contacts listed above).


Board on Health Sciences Policy

Committee on Prepositioned Medical Countermeasures for the Public

Robert R. Bass (chair)

Executive Director

Maryland Institute for Emergency Medical Services Systems


Tia Powell (vice chair)


Montefiore-Einstein Center for Bioethics, and

Professor of Clinical Epidemiology and Clinical Psychiatry

Albert Einstein College of Medicine

Bronx, N.Y.

Margaret L. Brandeau

Coleman F. Fung Professor of Engineering, and

Professor of Medicine

Departments of Management Science and Engineering and Medicine

Stanford University

Stanford, Calif.

Brad Brekke

Vice President of Assets Protection

Target Corp.


Robert L. Burhans


Office of Health Emergency Preparedness

New York State Department of Health (retired)


Louis Anthony Cox Jr.


Cox Associates


Robert S. Hoffman

Associate Professor of Emergency Medicine and Medicine (Clinical Pharmacology)

New York University School of Medicine, and


New York Poison Control Center

New York City

Daniel Lucey

Adjunct Professor of Microbiology and Immunology

Georgetown University Medical Center

Washington, D.C.

Kevin Massey

Director of Lutheran Disaster Response

Evangelical Lutheran Church in America


Erin Mullen

Assistant Vice President

Rx Response

Pharmaceutical Researchers and Manufacturers of America

Washington, D.C.

Joanne M. Nigg


Department of Sociology

University of Delaware


Herminia Palacio

Executive Director

Harris County Public Health and Environmental Services


Andrew T. Pavia

George and Esther Gross Presidential Professor, and


Division of Pediatric Infectious Diseases

School of Medicine

University of Utah

Salt Lake City

Stephen M. Pollock1

Herrick Emeritus Professor of Manufacturing, and

Professor Emeritus of Industrial and Operations Engineering

University of Michigan

Ann Arbor

Reed V. Tuckson2

Executive Vice President, and

Chief of Medical Affairs

UnitedHealth Group

Minnetonka, Minn.

Jeffrey S. Upperman

Director of Trauma

Children's Hospital of Los Angeles, and

Associate Professor of Surgery

Division of Pediatric Surgery

Keck School of Medicine

University of Southern California

Los Angeles


Clare M.A. Stroud

Study Director

1 Member, National Academy of Engineering

2 Member, Institute of Medicine

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