US Health Care Earns an "F" for poor flu supply chain practices

Posted on Wednesday, January 17, 2018 at 10:32AM by Registered CommenterScott McPherson | CommentsPost a Comment

America's struggles with a major flu epidemic (my words, but I will be borne out) have produced several revelations.  The first is the complete lack of institutional memory when it comes to pandemic supply chain preparations. If I taught this mantra once, I taught it a hundred times, in a hundred lectures and seminars, from coast to coast, over a period of eleven years:  Check your upstream and downstream suppliers for their pandemic preparedness. If they are unprepared, find new or secondary suppliers. 

This is not just a health care warning.  It is intended for any organization that does anything, makes anything, or services anything.  If you search my blogsite, you will find previous references to this need.  I have spoken to people all over America about it.  I have had conversations with organizations as large as 3M  -- and people as well-known and important as Michael Dell -- about pandemic supply chain management.

In my lectures, I also point out that Nature has a way of piling on disasters.  For instance, 75% of all flu pandemics occur outside of flu season.  We are coming up on the 100th anniversary of the 1918 Spanish Flu pandemic, the worst flu pandemic in recorded history.  It is commonly believed to have started on a farm in Kansas in the spring of 1918.

Well, Nature really piled on this time.  Difference is, it piled on in ways we were not thinking about.  Puerto Rico used to (pre-Hurricane Maria) manufacture the overwhelming majority of IV bags that are used in American hospitals.  I am sure you have read, heard or seen the news stories. Because those facilities are only now getting their power back, there are severe shortages of those IV bags everywhere.  Here are two stories:

But the warning signs were there, as early as last October.  My friend Dr. Michael Osterholm of CIDRAP and one of the world's leading experts on infectious disease said as much.  In a Newsweek story dated October 12, 2017:

Michael Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota tells Newsweek that the United States relies on foreign trade for many medical needs. About 30 essential items, these include hospital supplies like IV bags and everyday drugs, are made outside of the U.S. A pandemic in India or China could keep people home from work, which would impact manufacturing.

“If anything happens to disrupt the supply, we wouldn’t have any of it,” Osterholm asserts. “We would suddenly see a tremendous amount of collateral damage,” he warns, stressing that it’s not the flu infection itself that could be deadly, but rather the consequences that follow. “The flu will accentuate all of the other health problems that we have.”

Bingo, Mike.  As usual, you hit the nail on the head.  Another warning shot was fired in October by Modern Healthcare, . An excerpt:

Sodium chloride and dextrose are vital drugs used every day in hospitals around the country, said Chris Snyder, drug information pharmacist at Cleveland Clinic who manages shortages and recalls.

"We're talking about two manufacturers that support nearly the entire U.S. and one of them is out and the other manufacturer doesn't have enough supply to make up for it," he said. 

While the Cleveland Clinic has the benefit of a drug compounding facility on-site that will partially insulate it from the shortage, Chief Pharmacy Officer Scott Knoer said he is waiting for the other shoe to drop as other suppliers are exhausted.

"The whole country will be scrambling," Knoer said. "I'm waiting for the cascade effect of this. This has major implications for hospitals everywhere."

The latest shortage is 
one of many in recent years resulting from manufacturing delays. Experts blame a lack of competition among drug manufacturers, which are increasingly consolidating to offset high production and compliance costs. 

Baxter and ICU Medical—which 
acquired Hospira from Pfizer in February—provide the bulk of IV fluids, while B. Braun provides a much smaller share. 

We knew we were going to have shortages of IV bags two full months before this year's flu epidemic erupted.  And yet the wheels turned slowly in Washington, with only recent movement toward permitting the importation of IV bags and saline from nations such as Switzerland.

But the hospital industry is suspiciously sounding like the Claude Rains character from Casablanca.  They are shocked -- shocked! -- to find there are supply chain problems with IV bags, blaming others (perhaps accurately) while not accepting a measure of blame themselves for allowing such conditions to thrive.  No one had a problem buying IV bags on the cheap from Baxter, manufactured in one location (what I call "castling oneself into checkmate").  That is, until Maria.  Putting all your IV bags into one basket was a terrible and possibly fatal strategy. 

Now we are also seeing spot shortages of antivirals such as Tamiflu and its generic equivalent. From WSB Atlanta:

How we have drifted (flu people get the pun) from the razor-sharp pandemic preparedness mindset of 2006-2009 into the funk we are currently in today.  We had a pandemic in 2009, but it was not nearly as lethal as we feared.  For that we say Thank the Maker!

I thought we had retained that knowledge and those lessons and cautionary tales.  That is one reason why I ceased writing blogs about pandemic preparations.  Seems I was wrong.  We need a complete reboot of the awareness and education efforts from the last decade.

The effort begins anew for me, today.


Chikungunya Arrives in Tallahassee

Posted on Monday, June 23, 2014 at 11:10AM by Registered CommenterScott McPherson in , | CommentsPost a Comment

As Angelina would say:

"Well, well."

The Tallahassee Democrat is reporting that two cases of chikungunya virus have been detected in my town.  Both cases are "imported"; that is, the victims contracted the virus abroad and then returned to Tallahassee.

In one case -- communicated to me by one of my spies -- a faculty member of The Florida State University's geology department contracted chikungunya virus while in Haiti doing some field work. 

As of June 14th, there were 42 confirmed cases of chikyngunya in Florida.  All, apparently, imported.

Alabama DoH: "No new viruses, no new bacteria" in Dothan cluster

As I type this, the top Alabama health official is holding a press conference.  And a major tip 'o the cap to my buddy Mike Coston for giving me the link!

The health officer says there are three different agents at work in the cluster:  Rhinovirus (4), influenza (I missed the number), and (3) bacterial pneumonia infections. There were multiple and overlapping infections in several of these cases.

The hubub, this official states, is due to the heightened states of alert pertaining to H7N9 and MERS-CoV.

"A clustering of common organisms" is the reason why this group of disassociated illnesses was grouped together.

One death was aged 34; the other was age 55. 

According to this man, "WNL" means "Within Normal Limits," referring to tests.  He says it also means "We never looked," referring to the individual persons who fell ill.  It was the number of persons falling so ill, in such a short timeframe and in such a small area, and in such an environment as we are working in today with H7N9 and MERS, that prompted the closer inspection. 

I like his candor and his folksy demeanor.   Case closed.

However, the question is still out there on Houston.

Are Dothan, Houston mystery illnesses linked? 

The cases all come from nowhere.  They involve bright, energetic, athletic students.  They begin feeling feverish, exhausted, shaken. Then they experience violent seizures, are sent into a medically-induced coma.  And then, for two of the three afflicted students, they die.

The Houston Chronicle reports from early May are chilling.  Students 60 miles apart, with no apparent links, succomb to the same symptoms.

Now, in Dothan, Alabama, we are seeing a hauntingly familiar situation unfold.  With the exception of the seizures, the symptoms are strikingly similar. 

A television station much closer to the outbreak -- NBC affiliate WPMI, Mobile/Pensacola, is reporting that:

Doctors investigating the illness have not yet found a common denominator in the patients, whose ages range between the 20’s and 80’s, other than their symptoms. Doctors tested samples from the 7 patients at the state health lab to determine if there is from them to find “strain matching fingerprint” she added.

Doctors are analyzing those tests with investigators from the Centers for Disease Control & Prevention’s Atlanta office. State health officials, The Alabama Department of Public Health and the Centers for Disease Control Respiratory Laboratory are analyzing lab tests from all seven patients. Officials hope to have preliminary results on the samples back by Wednesday or Thursday morning.

Okee dokee, it is late Thursday morning.  What do we know? 

All eyes on Dothan, Alabama (!) respiratory outbreak 

OK, THIS is unsettling.  Prior to this week, I only knew Dothan as the city where my parents were married, and where my wife, stepson and I would stop on the way to Tuscaloosa during his recruitment by the Crimson Tide. Dothan is about a two-hour drive from Tallahassee, in southeastern Alabama.  It is a large town, and a crossroads for persons traveling from Interstate 10 to Interstates 65 or I-85.

But now, Dothan is known as the epicenter of an outbreak of a still-unknown respiratory outbreak.  And forgive me if it is a bit worrisome to me on several levels.

First, the situation on the ground here in Tallahassee:  I am on Month 5 of some sort of mystery ailment.  It is, apparently, some sort of allergy, brought on by (I theorize) an Alien Spore Cloud of some magnitude.  I say this because, roughly, 2000% of Tallahasseans are suffering as well.

A couple of weeks ago, I traveled with my beautiful wife to a conference she was working in Cocoa Beach.  I was able to get some quality body-surfing time, although my "rescue" at the hands of misguided marine biologists who misinterpreted my body surfing as the throes of a beached whale was not appreciated.  Just kidding on that one.  I said to myself, "Self, this salt air and seawater should wipe out whatever it is in my sinuses that is causing me Hell." 

WRONG!  later that day, I restarted my routine of sneezing and dealing with a runny nose.

It seems that every other Tallahassean, including my wife, is suffering the same fate. So you can see where a respiratory incident could easily be misinterpreted -- until people stop breathing, that is.

Back to the Dothan cluster.  From the Alabama Department of Public Health, dated 5/21/13:

 On 5/16/13, a pulmonologist in Southeast Alabama reported to the Alabama Department of Public Health (ADPH) that three patients had been hospitalized with cough, shortness of breath, and pneumonia, were on ventilators, and had no known cause for their illness. The ADPH and the Houston County Health Department began an epidemiology investigation to interview the families about travel and exposure. Specimens were requested and submitted to the ADPH Bureau of Clinical Laboratories (BCL) in Montgomery.

On 5/17/13, BCL reported one of the three patients tested positive for 2009 H1N1. On 5/18/13, this patient died. On 5/19/13, the same hospital reported that a transferred patient on a ventilator with respiratory symptoms had died. On 5/19/13, this hospital had nine additional patients present to the emergency department with influenza-like illness and three of those patients were admitted. Specimens have been collected on all patients. The BCL has tested all specimens on a PCR flu panel and one tested positive for AH3. The specimens were also forwarded to CDC for additional testing.

The story gets more interesting, as three additional residents have been diagnosed with -- whatever.  From Montgomery, Alabama television station WSFA 12:


The number of mystery illness cases affecting Alabama is growing. Wednesday, Alabama Department of Public Health spokeswoman Dr. Mary McIntyre confirmed the number rose to ten overnight from a previous report of seven. Two people have died.

"Since we sent out the alert to providers last night, we have had three additional patients/cases," Dr. McIntyre told WSFA 12 News. "These patients all have the same symptoms of cough, shortness of breath and "something" on their chest x-rays," she explained.

Of interest is the fact two of the afflicted -- including one of the deaths -- tested positive for influenza.  One of the deceased tested positive for H1N1, and another patient tested positive for A/H3. Whether this was seasonal H3N2 or swine H3N2 is not known.  My hunch is it is the more virulent form of H3N2 that we saw at the tail end of this flu season.  That caused such a spike in elderly deaths that it prompted the CDC to do a pretty exhaustive analysis -- the spike in deaths was that great.

This incident might not have generated the corresponding amount of publicity, were it not for the vigilance in the face of H7N9.  H7N9, by the way, seems to have taken a vacation. 

Of the original seven cases, three remain hospitalized.  Two were discharged, and two met their Maker.

ABC News theorizes that these cases may not be a cluster of anything except overreaction. However, we know that three people are still on ventilators and the community is on pins and needles.

NBC News reports that Alabama health officials are not taking any undue chances.  While I doubt the medical facilities have any negative air-pressure rooms (we are talking rural Alabama here), they are taking all the precautions they can:

The hospital is using respiratory precautions, which include requiring staff to wear special N95 masks that reduce the chance of infection.

With H7N9, MERS-CoV and God knows what else out there, no one is taking any chances.  The CDC is a three-and-a-half-hour road trip away; close enough to spend quality time in Dothan.  

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