Impacts of The Failing Medical Supply Chain in the COVID Era
October 28, 2020 8:02 AM   Subscribe

Yesterday, scientists and supply chain experts participated in an /r/AskScience AMA, sharing the following: "Since March, clinical microbiology laboratories have faced shortages of testing supplies, including SARS-CoV-2 molecular test reagents. Due to the growing demand and need for COVID-19 testing, production of supplies required to test for other infectious diseases has dwindled. This has led to a ripple effect of shortages and is causing a major delay in testing for common infections, such as urinary tract infections, sexually-transmitted infections including chlamydia and gonorrhea, gastroenteritis and cystic fibrosis."

You can review their findings here.

In surveying labs, their findings show:
-73% have a shortage of commercial testing kits for SARS-CoV-2
-65% of labs have a shortage of non-COVID-19 testing supplies for detection of routine bacteria (including the bacteria causing strep throat, pneumonia, bronchitis and urinary tract infections )
-70.8% of labs have a shortage of supplies for molecular detection of sexually transmitted infections
-17.6% have a shortage of supplies for mycobacteria testing (including testing for tuberculosis (TB), Buruli ulcer, and pulmonary nontuberculous mycobacterial disease)
-50% of labs have a shortage of supplies for routine fungal testing (ranging from superficial, localized skin conditions to deeper tissue infections to serious lung, blood (septicemia) or systemic diseases)

But this isn't just about lab supplies and equipment. There are also major logistical, labor, data and other shortages, issues or needs at the moment, right at a critical point before we head into a winter that will likely be a very dark time in the COVID era. And this is occurring after early failures at the expense of patients, with no improvements since.

Others are calling for Supply-Chain Collaboration, but will that really work without a coordinated national response? These shortages have yet to be fixed.

The AMA included:
-Dr. Amanda Harrington - PhD, D(ABMM) - Director, Clinical Microbiology Laboratory; Associate Professor and Vice Chair for Clinical Pathology; Department of Pathology and Laboratory Medicine, Loyola University Chicago
-Dr. Melissa MIller, Ph.D - D(ABMM), F(AAM) - Professor, Pathology & Laboratory Medicine; Director, Clinical Molecular Microbiology Laboratory; Director, Clinical Microbiology Laboratory, University of North Carolina School of Medicine
-Sherri Goodlove - Vice President, Marketing, Association for Supply Chain Management
-Peter A. Bolstorff, CSCP, SCOR-P - Executive Vice President, Corporate Development, Association for Supply Chain Management
-Dr. Susan Butler-Wu, PhD, D(ABMM), SM(ASCP) - Associate Professor of Clinical Pathology, Keck School of Medicine, University of Southern California, and Director of Clinical Microbiology at LAC+USC Medical Center.

Some of the most honest but disheartening responses in the AMA:
-Question: Back in the spring, non medical labs at our institution and many others donated reagents and supplies to support testing efforts. Is this type of contribution still ongoing, or has the supply chain as a whole just been altered? Is there a way to do this redistribution more systematically?
-Answer: There have been and continue to be emergency response supply chain actions at local and state levels. Those actions benefit the population in those areas directly affected but because the actions are done mostly outside the 'the system', transparency and collaboration are difficult at best.

There has been a concerted effort to report an aggregated view of testing supplies from manufacturers but there is no end-to-end plan that coordinates the source, make and deliver processes nationally or even regionally. We've seen only incremental improvement since May and we are still wasting 60% of test capacity due to shortages.

Question: I'm curious about geographic trends. Are some regions/states/countries more affected by supply shortages than others?
Answer: Every country developed or evolved it's own supply chain strategy in support of its COVID-19 response including testing capacity. Anecdotally, we have global stakeholders that have stated that coordinated response, public support and transparent data have led to significantly better impact.

Question: Why haven’t rapid tests become more available? Does money have something to do with it?
Answer: From a supply chain point of view -- getting to FDA approval for the test is a milestone but being able to effectively plan, source, make at scale, and deliver at scale is a nearly equal challenge. The pandemic is bringing to light that successful impact at the patient level requires a tight sync between both the development and supply chain teams.

Our next challenge will be the end-to-end COVID-19 vaccine supply chain and the impact it will have on COVID testing requirements. Stress testing critical care supply chains will be 'a thing' in the next 6 months.

If you're a member of a clinical microbiology lab and would like to get involved in data collection efforts, you can email the team for details.
posted by glaucon (18 comments total) 27 users marked this as a favorite
That 60% number is... oof.
posted by deludingmyself at 8:59 AM on October 28, 2020 [1 favorite]

I hope what comes clear from these answers is a sense of how sensitive and fragile all the efforts are: "Behind almost every lab test is an amazing medical laboratory scientist making sure the results are accurate and completed as quickly as possible. A lot of focus has been put on 'testing', which has largely meant collection devices (swabs), test kits, and instrumentation. I'd like us to add 'people power' to that equation as well. We entered this pandemic with a shortage of laboratorians, and COVID has only pushed that even further. Although instrumentation does a lot of the work to perform lab testing, so much of what is getting done, when it comes right down to it, is done by an individual."

Response, successful emergency response, is very much down to individual care and effort. As a very human, highly labor-intensive activity, breakdowns due to stress or mismanagement are major concerns.

Doing things right is tremendously antithetical to low detail, disconnected and "get-er-done" leadership.
posted by bonehead at 9:13 AM on October 28, 2020 [19 favorites]

That list reads like a "Who's who of who we should have called to find supplies back in March" as opposed to *checks notes* Jared K's buddy from college looking around on Craigslist.
posted by sexyrobot at 10:30 AM on October 28, 2020 [13 favorites]

On top of everything, the COVID-19 pandemic has shown us how fragile our civilization really is. It really seems like we're a couple of dedicated people away from total collapse and it's not getting better.
posted by tommasz at 10:38 AM on October 28, 2020 [5 favorites]

This has been going on for more than six months. That would have been time enough to build a factory, or retool one. Perhaps not under normal circumstances, but under wartime conditions it's been done before. Six months is not enough time to train MDs, RNs or PhDs, but it could have been time enough to train or re-skill an army of grunt-level routine-task thing-doers. It's not as though there's a shortage of unemployed people who need the work, and their wages could have been a fine form of stimulus.

Nothing about this coming winter is a surprise. The failure to organize and mobilize for what's coming is not solely an American problem; this crisis is going to prove more lethal and disruptive than any my country has seen in its modern history, on the scale of our largest wars, but what affected country has made maximum effort to prepare?
posted by justsomebodythatyouusedtoknow at 10:57 AM on October 28, 2020 [19 favorites]


On a related note (test availability was one of the first questions), I put together a twitter thread on diagnostic test parameters and their impact on the pandemic testing results. Use or abuse, as is your wont.
posted by Mental Wimp at 11:28 AM on October 28, 2020 [5 favorites]

I have a little experience of this from a UK point of view. My employer is involved in COVID-19 Genomics UK (COG-UK), sequencing lots and lots of SARS-CoV-2 for viral surveillance.

In the first few weeks after the 26th March lockdown we had problems getting supplies, with items being redirected to the testing effort or the supply chain being disrupted (nationally and internationally) by the lockdown rules. As a research institute we have some experience in mixing our own reagents from more basic chemicals and so we went down that route (I think the supply lines are more stable now).

What we were not short of was lab staff. With all our other wet lab research put on hold we had more than enough to handle the sequencing prep. The institute even suggested that people with the right skills could volunteer to work in the government testing labs. Everyone was being paid whether they could do anything useful at home or not; so if they had no pressing commitments at home they could help with national testing effort.
posted by antiwiggle at 11:34 AM on October 28, 2020 [13 favorites]

After coming down with a bad cough a few weeks ago, I went in for a Covid test. A package of five cotton swabs was opened and I was offered the choice to pick one to use in sticking up my nose. The remaining four were thrown into the trash.

I'm still curious if this is normal procedure. The only possible reason I could think for doing this is that a random selection of a swab reduces error in some way unclear to me. But I'm not sure why I was given a choice in the first place: my grubby fingers could have easily been contaminated with viral RNA on the way to the test site (RNase is ubiquitous and I could have easily touched something in a facility where sick people congregate).

Whatever the reason, that kind of waste must propagate up to exacerbate all kinds of problems we are seeing at large scale. At the clinical level, where I was, where 80% of valuable, unused cotton swabs may be sent to an incinerator or landfill, say. Or at research labs, reworking their internal processes to help local public health orgs with testing, which need robot pipet tips, PCR reagents, and other sterile gear that are also in short supply. Add to that shortages of PPE for both clinics and hospitals.

It all slows down and limits testing and treatment options. I could only imagine how much better we might have done if we had a global (or even country-level) wartime effort that commandeered companies that specialize in supply chain optimization: shipping and logistics, consumer electronics, online retail, etc.
posted by They sucked his brains out! at 12:07 PM on October 28, 2020 [3 favorites]

On top of everything, the COVID-19 pandemic has shown us how fragile our civilization really is. It really seems like we're a couple of dedicated people away from total collapse and it's not getting better.

Seems to me we have quite a few people very dedicated to causing that collapse.
posted by evilangela at 12:17 PM on October 28, 2020 [10 favorites]

Unspoken in this discussion (at least that I saw) was the role of consolidation and/or monopolization for components in the supply chain. When materials are only available from one or two suppliers, who may only have one or two facilities producing a good, a shutdown or other disruption can cause massive shockwaves through the system.

This is because we have emphasized capitalism over free markets. In capitalism, the goal is to get big to crush out competition. Free markets, on the other hand, are healthiest when there is robust competition.
posted by Big Al 8000 at 12:37 PM on October 28, 2020 [7 favorites]

Related deep dive into the ongoing N95 mask shortages: N95 masks save lives. So why are they still hard to get this far into a pandemic? [WaPo]
posted by Hairy Lobster at 1:09 PM on October 28, 2020 [5 favorites]

Six months is not enough time to train MDs, RNs or PhDs, but it could have been time enough to train or re-skill an army of grunt-level routine-task thing-doers.

Yep. If my university is in any way typical, there are a lot of frustrated PhD biologists out there whose research was shut down in the spring and summer, and which is still probably highly disrupted. Most of these biologists have no specific expertise in, say, virology, or epidemiology, but nevertheless have relevant background with bench science that would make them relatively easy to train up to do things like manufacture reagents, or do quality control testing, or any other number of things, and with most people's labs closed or limited, a lot of them would have been happy to contribute to a mass effort to produce tests for public health. A competent government could have mobilized this pool of labor, which mostly spent the first few months of the pandemic at home writing applications for research grants that most of them will not win because the number of grants available has not increased despite their increased time for grant writing, to help with a coordinated national response to make testing readily available for everyone. Internally, my university took some steps in this direction anyway, but without national coordination there's very little that can be done.

Instead these incurious venal buffoons that have managed to grab the levers of power in our government did... nothing. The failure of the medical supply chain this year is not because we lack the capacity to produce, not because there is a lack of skill or will among the populace. It is solely because government refused to act, and despite what libertarians might imagine, markets do not coordinate to solve crises in this way.
posted by biogeo at 3:20 PM on October 28, 2020 [9 favorites]

Any normal US administration during a pandemic would have rejoiced at the chance to enact all kinds of new invasive laws, creating new departments without legislative oversight, and seizing all kinds of power based on the obvious fact that infected people can cross state lines. Think of how much insanity happened following 9/11 - PATRIOT Act, TSA, DHS, at least one completely unnecessary war. For the most part, these all passed with little opposition from the opposing party. And we now know that they were knee-jerk reactions that did little to actually address the problem and mostly eroded our rights.

George W. Bush, considered a pretty weak president beforehand, had his approval rating skyrocket to 90, and Giuliani's went up to 79. Bush was reelected with a majority of the popular vote; Giuliani became Time Person of the Year, was knighted, and seriously considered as a presidential candidate.

But this year... we got somehow got something worse than any of this. What power-hungry leader doesn't want more power? Or be exalted? We didn't even get someone with the smarts to leverage it into their own benefit. We got a charlatan who doesn't even know how to pretend to lead.
posted by meowzilla at 7:11 PM on October 28, 2020 [1 favorite]

I'm not an infectious disease epidemiologist, but my biostatistical and epidemiological training and experience has allowed me to help real ID specialists to design, implement, and analyze studies. Fortunately, I'm in a division of a school of public health that has lots of such folks, some of the best in the world. I've focused on trying to understand how concomitant medical conditions affect people's ability to cope with isolation, PPE, and distancing interventions, and to maintain their health under those constraints. I've also worked with folks developing an app to identify and overcome adverse social determinants of health. And in my main area of focus, colorectal cancer screening, I've worked to make healthcare providers aware of alternative screening methods like fecal immunochemical tests to reduce exposure to colonoscopy during the pandemic, while still reducing long-term risk. Not central to the main problem, but I'm trying to use my time to help. All my non-ID colleagues across the country are doing this, too.
posted by Mental Wimp at 8:40 PM on October 28, 2020 [3 favorites]

I have no idea what skills required to manufacture and distribute quality-assured reagents at an unprecedented speed, but the difficulty of ramping up some other clinical capabilities seems to have been woefully underestimated in my part of the world.

How teenagers ended up operating crucial parts of England’s test and trace system

Is this a case of picking one or two from out of fast, cheap, good? Or are there successes that aren't as visible as the shortages? The food supply chain seems to have coped better than I anticipated so far, but there will no doubt be knock-on effects from labour shortages.
posted by GeorgeBickham at 5:31 AM on October 29, 2020 [1 favorite]

Fast, cheap and good?
More like fake, cheat and steal.
But you get to pick all three.
posted by fullerine at 6:15 AM on October 29, 2020 [2 favorites]

Unspoken in this discussion (at least that I saw) was the role of consolidation and/or monopolization for components in the supply chain. When materials are only available from one or two suppliers, who may only have one or two facilities producing a good, a shutdown or other disruption can cause massive shockwaves through the system.

This has been the story I want to read since about the end of April, six weeks after the mid-March lockdown here. I was struck by a continuing lack of basic supplies at the superstores like Target and Walmart, thinking to myself, "isn't it the entire fucking point of these huge stores that they dominate the global inventory for staples?" Meanwhile Target was out of toilet paper and paper towels for MONTHS. They may still be! Do you buy those 10oz mini cans of Coke? They've become unfindable, apparently due to an aluminum shortage? Then you find that the dollar stores and bodegas in the city have these things and the "WTF" intensifies.

Different distribution channels, I'm guessing, but the question remains: why even have Target and Walmart if their massive distribution networks can be clogged with a toothpick? This abject failure of the champions of capitalism is really, really glaring to me and I'd like some answers.

We can speculate that the factories were snowed under, but for that long? I mean, it was like the country had retooled for war! "Sorry, no chocolate for awhile and you're going to have to recycle your own aluminum foil," I can understand, but "sorry, the fairly automated household paper manufacturing industry can't operate" implies a story that didn't make the, er, papers. Was it indeed a problem in acquiring wood?
posted by rhizome at 10:05 AM on October 30, 2020 [3 favorites]

My lab is on our third type of vtm for covid testing alone. We've run out of agar, pipettes, tubes, slides, O neg blood, patience, etc. Chlamydia/gonorrhea testing is now sent across the country for testing because we can't get supplies in house. The strap on my N95 (issued to me in March) finally failed to the point that I was allowed a new one. It was nice not smelling 7 months of my own breath.
posted by MaritaCov at 4:19 PM on October 30, 2020 [8 favorites]

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