WASHINGTON -- Hospitals nationwide are rationing adult tetanus shots, reserving them for burn victims and other severely injured patients, because of a huge shortage of the crucial vaccine.
It's one of the worst drug shortages facing hospitals in years -- and don't expect it to be the last. Shortages of medications that hospitals use every day are occurring with more frequency, and worse, they more often involve products with few good alternatives.
While experts can't point to a shortage that has cost a life, it's a possibility that haunts doctors and pharmacists struggling to cope.
"It's really hard to talk about rationing care," said Linda Tyler, pharmacy manager at the University of Utah Hospital. The hospital hasn't offered adult tetanus booster shots since fall, reserving scarce doses for high-risk patients with burns, infected wounds or other severe trauma.
"We use it 'til it's gone, and when it's gone, it's gone," she said.
So far the tetanus crisis concerns only adult versions of tetanus vaccine, not children's vaccine. But Centers for Disease Control and Prevention experts are watching closely to see if the shortage spreads -- and worrying about adult illnesses this spring, when vaccine demand rises along with a seasonal jump in injuries.
Supplies already were tight because of production difficulties when Wyeth-Ayerst Laboratories last month stunned hospitals by suddenly ceasing to make the vaccine altogether, calling it "a business decision."
CDC praises the sole remaining manufacturer -- Aventis Pasteur -- for working around the clock to brew more of the millions of doses needed annually. But each batch takes 11 months to make, so relief isn't expected before year's end.
It's not the only shortage. Abbott Laboratories has run out of lifesaving intravenous Isuprel, kept on hospital "crash carts" to revive cardiac arrest victims, because of a problem with its ingredient supplier. Doctors are using workable but somewhat less desirable alternatives.
Eye surgeons are stretching final supplies of Wydase, important in numbing eyes for cataract and other surgeries after Wyeth abruptly quit making it, too.
Also in short supply is the powerful painkiller fentanyl, and Narcan, used to reverse morphine overdoses.
"We call and beg and plead" for doses, said Carla Gill, associate director of the Johns Hopkins Hospital pharmacy. "We get dribs and drabs of what we've ordered," and pharmacists then furiously work to stretch supplies and find alternatives.
Nobody keeps good statistics, but the nation's largest hospitals and the Food and Drug Administration agree shortages -- lasting from weeks to months at a time -- are increasing from a few critical drugs a year to about a dozen.
Why? Sometimes a company's ingredient supplier quits making a key ingredient, or demand temporarily spikes.
Sometimes FDA discovers health-threatening violations in a factory and temporarily halts production -- partly to blame for last fall's flu vaccine shortage.
Some manufacturers decide a product is not profitable enough. With increasing drug company mergers, there are fewer competitors making the same medicines anymore and thus fewer that can quickly pick up the slack.
Companies are notoriously tightlipped in explaining shortages. Take Wyeth, which cites only "manufacturing-related issues" in killing Wydase, made in a factory FDA had cited for repeated violations.
Shortages encourage price-gouging, sometimes doubling, says Hopkins' Gill who, a day after the Wydase announcement got a call from a distributor with a stockpile looking to make a deal.
Hospitals are feeling shortages sooner than ever before because, faced with steep medication costs, most now keep only a few days' supply in inventory.
The FDA and CDC are studying which critical drugs are most at risk for shortages, and FDA officials are trying to ease the situation by finding overseas ingredient suppliers or encouraging small drug companies to make a larger competitor's castoff.
But to help hospitals cope fast, Utah's Tyler is working with the American Society of Health System Pharmacists to issue Internet bulletins warning of impending shortages and listing any alternatives.
What's next? Tyler is warily watching whether a medicine crucial for heart surgery that's now on backorder will turn into a real shortage. "It's put us in a panic. ... If we're unable to get protamine, we'll have to think about canceling surgeries that aren't emergencies," she said.
"This is a tremendous headache," she added, and it's only going to get worse.
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