Here's some discomfiting news. I hope JC doesn't need any of these meds.
Tucson, Arizona Wednesday, 15 August 2001
Flu shot shortage to repeat
It's just one part of a national problem that has vital drugs in short supply
By Carla McClain
ARIZONA DAILY STAR
If you think waiting for hours in long, hot, angry lines for scarce flu shots was last year's bad dream, think again.
We are facing yet another major delay in getting the high-demand vaccine this year, with full supplies not expected until the end of December.
Ominously, the flu vaccine shortage is not a one-shot deal but is part of a nationwide shortage of vital drugs that has kept hospitals scrambling for more than a year to get what their patients need, with no end to the problem in sight.
Although Tucson hospitals insist the shortages have not yet hurt patient care, they are blamed for three recent deaths in California and have forced hospitals and doctors here to switch to unfamiliar and inefficient alternative therapies.
At any given time, hospitals have run short of narcotic painkillers, heart surgery drugs, eye surgery anesthetics, tetanus vaccine, powerful antibiotics, malaria drugs, tranquilizers, steroid injections, rattlesnake antivenin, muscle relaxants and cardiac arrest drugs.
"The problem is not letting up, and I'm afraid we're in this for the long run. It's ongoing, and it's hitting everybody," said Gilbert Romero, director of pharmacy for Tucson's largest hospital, Tucson Medical Center.
"In many cases, it's forcing us to switch to alternative drugs - drugs doctors aren't familiar with, and that causes lots of inefficiency. Every single day, we have to figure out what drugs are short, and why, and for how long, and how to substitute for them, and we see no end to it."
But it is the flu shot shortage that is now poised to hit the general public hardest in coming months, although officials are hoping to avoid last year's near-panic over it.
Unlike last year, plans are under way to be sure those at high risk for serious influenza complications - the elderly and patients with chronic diseases - do not get stuck in long lines outside grocery stores waiting for shots that run out, say health officials.
"The first doses that come in will go to the high-risk people. We're asking everybody else to hold off, and we're going to make that the message in a major public education campaign," said Pima County medical director Dr. Elizabeth MacNeill.
"We can't force anyone to do that, but we're going to do everything we can to see that it happens, and make sure we don't have a repeat of last year."
For the first time in years, the county Health Department will get back in the flu shot clinic business, to make sure the first clinics - expected in October - target high-risk people only, MacNeill said.
"We pretty much stopped holding clinics, because the retail stores - the drugstores and grocery stores - were doing such a good job of it," she said.
"But this year we will have our own clinics, because it's the only way we can be sure the first vaccine doses we get go to the people who need them most. We've got our shot team back in action."
The nation's first batch of vaccine should appear by mid-October - about a month later than normal - according to an advisory from the Centers for Disease Control and Prevention.
More vaccine will be available in November, with the full supply widely available by late December. In the end, there will be more vaccine than last year, but no one really knows when it will get here, despite the predictions, officials admitted.
Flu vaccine was also promised in October last year, but didn't arrive until December, triggering the lines of panicky people.
"There has been no verification yet of any vaccine shipment, and it's supposed to be here in two months," said Jason Veazie, vice president of operations for the Phoenix-based Mollen Clinic, the group that contracts to hold flu clinics at Safeway, Fry's and Albertson's grocery stores in Tucson.
"All we can do is keep our fingers crossed. If it's only a delay, and not a huge delay, I think it will be OK. But if it comes in later than October, it unfortunately will be bad again."
Mollen is planning large store-based clinics for high-risk-only people and for the general public in October, but will hold off on corporate worksite clinics until November, Veazie said.
Last year's flu shot shortage was blamed on a laboratory shutdown by one of the vaccine's manufacturers and by the difficulty in growing one of the flu strains in it.
Similar dynamics are causing this year's delay and many of the other current drug shortages, officials say.
Only three drug companies today manufacture flu vaccine, compared with nine or 10 in past years.
Several drug companies have merged and others have been forced to shut down temporarily because of manufacturing violations, while others have discontinued making certain drugs and vaccine because of lost profits after patents expired, according to several studies.
"There's no doubt the FDA (U.S. Food and Drug Administration) has cracked down on some of the manufacturing processes," said Dan Kopp, pharmacy director for St. Mary's and St. Joseph's hospitals.
"And some of it has been pure business decisions - the bottom line. The upshot is that it's making our life miserable. There's no such thing as ordering and receiving a drug anymore. It's a constant struggle to keep what we need on the shelves."
The deaths of three patients in San Francisco last month have been indirectly connected to the drug shortage, according to a report by the American Society of Health-System Pharmacists.
When an outpatient surgery center was unable to get the injectable corticosteroid betamethasone - widely used on surgery patients and for many other acute medical conditions - the facility was forced to compound the drug, making it from its raw materials.
Contamination occurred during the process, resulting in bacterial meningitis in patients injected with it, killing three.
All Tucson hospitals are running short of these drugs, and one, TMC, did compound a similar drug, dexamethasone, when it ran out.
"We only used the drug externally on patients, so contamination was not an issue," said Romero, the hospital's chief pharmacist.
Doctors at University Medical Center have been warned not to use betamethasone or other corticosteroids "unless absolutely necessary," said William Fritz, the hospital's interim director of pharmacy.
"We have never compounded drugs here because of the huge concerns about contamination," he said. "Thank goodness we haven't been forced to do that yet. It's always a risk."
Tucson hospitals have recently been forced to find substitutes for the widely used painkiller fentanyl, as well as anti-seizure injectable phenobarbital, the narcotic-reversing Naloxone and, in some cases, the clotting drug protamine, vital for open-heart surgery.
"We haven't run out of protamine yet, but if we do there could be real consequences," Fritz said. "I know of no alternatives for it."
Hospitals are also still rationing the tetanus-diphtheria vaccine for adults - limiting it to high-risk wound and burn cases only. And shortages of several crucial childhood vaccines - for meningitis, diphtheria-pertussis-tetanus, and haemophilus influenza - are looming, said MacNeill.
"This is scary," she said. "Here we are in a very powerful, very rich country, forced to ration vaccines, leaving us potentially vulnerable to thousands of cases and many deaths.
"It's more like a Third World than a First World country."
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Current drug shortages in the United States
* Bacitracin injection (antibiotic)
* Corticosteroids (potent anti-inflammatories, immune-suppressants): betamethasone, dexamethasone and methylprednisolone sodium succinate
* Fentanyl (narcotic painkiller)
* Isoniazid injection (tuberculosis)
* Mesantoin (anticonvulsant)
* Nalbuphine (surgical pain control and anesthesia)
* Naloxone (narcotic reversal and shock management)
* Norepinephrine injection (extremely low blood pressure, cardiac arrest)
* Phenobarbital injection (sedative)
* Prochlorperazine injection (nausea and vomiting control)
* Protamine (blood clotting)
* Quinidine gluconate (malaria, irregular heartbeat)
* Succinycholine injection (muscle relaxant, for surgery and intubation)
* Tetanus-diphtheria vaccine
* Thiamine injection (to combat alcoholic malnutrition and disorientation)
* Wydase (cataract surgery)
Sources: U.S. Food and Drug Administration; American Society of Health-System Pharmacists
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