First wave of flu exposed gaps in supply chain

By Stephen Smith
Globe Staff / June 15, 2009

The arrival of swine flu in the United States exposed gaps in the supply chain that delivers medication, masks, and even testing swabs to hospitals and doctors' offices - shortcomings that could prove vastly more worrisome if a deadlier strain returns in the fall, officials say.

In Massachusetts, where the state health agency had to tap its emergency cache of flu-relief pills to supplement dwindling private supplies, the administration of Governor Deval Patrick is asking the Legislature to spend $1 million more to bolster the state stockpile, a request that is pending.

And across the nation, from sprawling federal agencies to small local health departments, disease trackers are urgently evaluating their response to swine flu, with eyes trained firmly on the autumn months.

That is when specialists expect two flu strains to circulate widely: the seasonal variety, capable of killing thousands, as well as the swine strain. The specialists operate against a backdrop of unpredictability, knowing that earlier novel flu strains sometimes petered out, while others roared back in mutated, deadlier forms.

Last week, global disease authorities declared that swine flu, known by the scientif ic designation H1N1, had reached pandemic status, a reflection of how broadly it had spread rather than its virulence. Yesterday's reported swine flu death in Scotland represented the first outside the Americas, health officials said.

The experience with swine flu has underscored how the agencies responsible for corralling dangerous germs often have no way of assuring whether pharmaceutical and medical supply companies have stocks sufficient to satisfy demand.

"We really didn't have a good handle on how much commercial supplies were out there, who had them, how rapidly were they being drawn down, and how to blend the public and private stockpiles so there would be no disruption of service," said James Blumenstock, chief program officer for public health practice at the Association of State and Territorial Health Officials.

"We have identified different shortcomings, gaps, weaknesses, possibly flawed or off-target planning assumptions that need to be inventoried and effectively addressed over the next several months," Blumenstock said. His association later this month will convene five dozen health officers, including John Auerbach, Massachusetts public health commissioner,, to analyze the handling of swine flu.

The supply shortages tended to be localized, Massachusetts health authorities said, but they reflected the vagaries of the fragile just-in-time economy that provides medical goods on a daily, as-needed basis.

Overall, Blumenstock and other specialists stressed, the nation's health system did not experience major upheaval with the arrival of the virus, first identified in the United States in late April. Still, Dr. Anne Schuchat, a top respiratory disease specialist at the US Centers for Disease Control and Prevention, conceded that "there have been some challenges."

"What's going on right now," Schuchat said, "is an intense effort working with state and local governments to try to gather those lessons learned and to understand what worked well, what didn't work well . . . and really get more ready for the fall."

Disease specialists fear that the appearance of twin flu strains could sorely tax the nation's healthcare system, which faced episodic supply shortages since the first cases of swine flu were diagnosed.

In the early days of the epidemic, Massachusetts doctors reported that some patients had trouble getting prescriptions filled for Tamiflu - the main medication used to treat the novel virus - as drug-store reserves ran low. As a result, the state Department of Public Health distributed enough antiviral medication from its stockpile to treat the flu or prevent it in 53,000 patients.

Some hospitals said shelves usually brimming with surgical masks, used to slow the virus' transmission, turned barren - and suppliers proved unable to replenish supplies in the standard 24-hour timeframe.

Hospitals sometimes found themselves in competition with each other for supply reinforcements, and there were instances when departments within the same medical center raced to get their orders in first.

"I definitely would not use the word 'hoarding,' but there was aggressive ordering of supplies early on in the outbreak and that caused uneven distribution," said Dr. Paul Biddinger, associate director of the Harvard School of Public Health Center for Public Health Preparedness.

Even one of the most low-tech of medical appliances, the basic swab, ran scarce as the state initially asked physicians to collect two nose or throat samples from patients with suspected cases of the disease.

"It reminded me that the supply chain is always one of the big issues we have to think of, that we have to figure out how we would have enough material in place for this kind of situation," said Mary Clark, director of the Emergency Preparedness Bureau at the Mass. health agency.

To help prevent future voids, the Patrick administration is poised to expand the state's reserves. It's unclear how many courses of flu medication could be purchased with the money requested by Patrick - the state currently has enough for 50,662 patients in its stockpile - but it would probably more than double the reserve. And given that children and young adults have accounted for three-fourths of swine flu cases, authorities are considering whether they need to include more pediatric doses.

But even in New England states where shortages were not as evident, the appearance of swine flu in a period when the threat from influenza is usually receding tested expectations about the timing and birthplace of a global epidemic.

"One key assumption is that pandemics will come to us from somewhere else, which basically means we will have time to prepare," said Dr. Jose Montero, New Hampshire's director of public health. "Well, this pandemic started in North America. So we were the ones trying to set up a system to assess risk, to assess severity, to assess infectiousness. With flu, you just never know."

Stephen Smith can be reached at stsmith@globe.com.