By Christopher Rowland

Doctors in the United States are prioritizing only the most critical patients and hospitals are rationing supplies of a crucial drug after a covid lockdown in China temporarily closed a GE Healthcare factory that is a vital source for a key ingredient in medical imaging.

The shutdown of the facility in Shanghai in April halted production of contrast media, an iodine solution that medical staff inject into blood vessels to allow a device such as a CT scanner or fluoroscope to see inside the body. Contrast media, also known as dye, is used virtually every hour in hospitals across the country to help measure arterial blockages around the heart, guide placement of stents in catheter labs, diagnose and treat strokes, and more. Oncologists use contrast to monitor cancerous tumors.

But with contrast supplies dwindling because of the manufacturing shutdown halfway around the world — part of stringent Chinese covid policies that kept workers at home and forced factory closures — doctors at many U.S. health systems are scrambling. They are prioritizing the most seriously ill patients and postponing more routine tests for those who can safely wait until contrast stocks are replenished.

GE Healthcare told hospital officials that capacity at the plant was 25 percent this week and that it expects to have supplies flowing normally again by the end of June. It has shifted production to a plant in Ireland and is flying shipments into the United States to speed delivery.

But getting through the next six to eight weeks could be difficult for local health systems reeling under the sudden supply shortage. Postponement notices for non-emergency appointments are already going out to patients.

“We have about five days’ worth on hand,” said Peter Cohn, a cardiologist at Southcoast Health’s Charlton Memorial Hospital in Fall River, Mass., where he said 10 to 15 routine heart scans had to be postponed this week. “It’s a crisis that I have never had as a clinician, that I have not had to deal with in my entire career.”

As a regional cardiac care center, Charleton Memorial handles referrals from an area between Rhode Island and Cape Cod. The cardiology staff is prioritizing heart attacks while asking patients with mild chest pain or other non-emergency signs of trouble to wait, Cohn said. He said patients have been understanding — as they have been throughout the pandemic.

“This is something that is completely out of our hands,” Cohn said. “It’s not something we have control over.”

The University of California San Francisco Medical Center also delayed some non-emergency cases, less than 5 percent of previously scheduled appointments so far. It also has begun asking doctors who order CT scans for patients to rate them as urgent or low priority. The 782-bed institution not only serves San Francisco but attracts patients for advanced care from throughout California and the world. It injects contrast media in patients for all conditions about 150 times per day, said Christopher Hess, professor and chair of the medical center’s radiology and biomedical imaging department.

“It is absolutely essential to the management of patient care. So many treatment decisions rely on imaging,” Hess said. “If imaging services sneeze, then the whole health system gets the flu.”

Hess attended a radiology conference in London this week where he said European colleagues told him their systems were less reliant on GE’s products and did not expect the disruptions to be as wide-ranging as in the United States.

The Greater New York Hospital Association posted a notice for its members Sunday that said GE’s contrast media supplies would be reduced by 80 percent for six to eight weeks, but GE Healthcare did not confirm that figure and said percentage cuts reported in the media have not been accurate.

The disruption, which began to unfold in the past two weeks, reveals once again how overseas, poorly diversified supply chains are vulnerable to a global health crisis. Shortages have crippled the U.S. health system again and again in the past two years.

Health workers struggled under shortages of N95 masks and other personal protective equipment, ventilators, and sedatives and other drugs. Lack of raw materials and manufacturing equipment hampered vaccine production. Meanwhile, hospitals temporarily suspended elective procedures such as knee replacements, first to limit infections and then, later in the pandemic, in response to staff shortages that forced them to close beds.

The supply crisis for contrast media carries a twist. It’s not because of a surge in demand from the coronavirus. This time non-covid patients are being affected because of an outbreak halfway around the world.

“It’s not about supply and demand. It’s a situation that we had no control over. It further demonstrates the fragility of the supply chain, where a few weeks’ disruption in manufacturing results in several months of disruption to patient care,” said Soumi Saha, vice president of advocacy at Premier, a large medical group purchasing agent.

GE Healthcare sales represent about one-third of the global market for contrast agent, but its dominance is even greater in the United States, according to doctors interviewed. The company does not publicly release information about market share.

Millions of patients globally could experience postponed tests in the coming month because of the shortage, said Matt Davenport, a University of Michigan radiology professor and vice chair of the American College of Radiology Commission on Quality and Safety. He said about 50 million scans using contrast — or nearly 1 million a week — are conducted annually in the United States.

In addition to reliance on a limited number of overseas factories, hospitals negotiate discounts by pledging to purchase nearly all of their supply from a single vendor.

“It’s an all-eggs-in-one-basket problem, where the supply chain is concentrated in one city and one country, and the health systems engage in preferred-vendor contracting,” Davenport said. “This means that the vast majority of contrast they might use comes from a single vendor. When that vendor is not available, they have nowhere to go for that contrast.”

Hospital pharmacists that rely on GE Healthcare contrast are working the phones and scrounging for supplies. Other global health-care companies make contrast media — Bracco, Bayer and Guerbet — but those companies are making sure existing hospital contracts are fulfilled and do not have large volumes to spare. In the meantime, Davenport said, doctors “are having to make difficult decisions on what to delay.”

GE Healthcare informed hospitals about the expected shortages in a letter April 19. The letter stated that “we expect supply relief by June 2022.” The Food and Drug Administration has listed two of its brand-name contrast agents — Omnipaque and Visipaque — as being in shortage.

A top GE Healthcare executive, Marco Campione, general manager of pharmaceutical diagnostics, told hospital officials Tuesday on a conference call organized by Premier that the Shanghai facility had returned to 25 percent capacity as of this week, Premier executives said. There were 700 participants on the call.

GE Healthcare said this week in response to questions that it is shifting more production to a plant in Cork, Ireland, and has begun sending cases of vials to the United States by airfreight to speed deliveries. It said it expects Shanghai to be 50 percent operational by the end of this week.

“After having to close our Shanghai manufacturing facility for several weeks due to local covid policies, we have been able to reopen and are utilizing our other global plants wherever we can. We are working to return to full capacity as soon as local authorities allow,” the company said Tuesday in an emailed statement. It called the scale and speed of the Shanghai lockdown unprecedented.