In 2022, the global supply chain for iodinated contrast media (ICM) was disrupted by COVID lockdowns -- and as it's likely that this kind of medical crisis will occur again, hospitals need to take proactive measures, according to a presentation delivered September 4 at the International Society for Computed Tomography (ISCT) meeting held in Brussels, Belgium.
It was a single factory shutdown that year "that put healthcare at risk across the entire globe, and uncovered some startling truths about how we practice medicine," said presenter Izabella Barreto, PhD, of the University of Florida in Gainesville.
"The [2022] crisis was a wake-up call," she said. "Did we listen?"
In 2024, the global contrast media market was $7.2 billion, and it is expected to increase to $12.9 billion in 2034, Barreto noted. Iodinated contrast comprises 65% of global contrast media use, and in the U.S., 93 million CT scans are performed each year, with 48% of these requiring iodinated contrast.
The key global iodinated contrast manufacturers are GE HealthCare, or GEHC (Omnipaque, Visipaque), Bracco (Isovue, Iomeron), Bayer Healthcare (Ultravist), and Guerbet (Optiray, Iomeron, Hexabrix, Xenetix, and Lipiodol). These firms have facilities around the world, from China, Ireland, Germany, and Italy to Norway, France, and Brazil, Barreto explained.
The global contrast shortage that occurred in 2022 was prompted by COVID lockdowns, which particularly affected GEHC's Shanghai facility -- the source of 80% of GEHC's iodinated contrast. More than half of all iodinated contrast supplied to the U.S. came from this facility. Between March and June, hospitals' existing inventories (one- to two-week supply) depleted, the U.S. Food and Drug Administration (FDA) officially reported a nationwide shortage of ICM, and hospitals began to implement shortage protocols and conservation strategies. By early 2023, however, ICM supply levels returned to normal in the U.S., but a global backlog continued.
The shortage was prompted by GEHC's Shanghai facility difficulties as well as by a depletion of available workforce due to COVID quarantines and illness, global shipping delays, and an inability of other manufacturers to quickly increase production of ICMs, Barreto said.
"Supply chain weaknesses exposed [hospitals'] excessive reliance on one manufacturer and facility, cost-saving inventory practices left no safety net when production stopped, a lack of coordination between healthcare systems hampered redistribution efforts, and manual inventory systems made it difficult to assess utilization and identify risks," she noted.
Unfortunately, vulnerabilities to this kind of medical crisis continue, ranging from systemic weaknesses (limited diversification, for example) and geopolitical instability (trade tensions, tariffs, wars) to economic pressures (consolidation among suppliers and centralized manufacturing), Barreto said. It's crucial for hospitals to develop ways to mitigate ICM shortages, and Barreto outlined two frameworks for both hospitals and policymakers across the U.S.:
Short-term crisis management:
- Triage and prioritize use of ICM, identifying the highest necessity exams, whether a test can be conducted without contrast, whether an alternative modality can be used, and whether the exam can be delayed. Some hospitals reported a reduction of emergency department contrast-enhanced CT exams of 85% during the crisis, and CECT use reduction measures contributed more to the reduction of use of ICM than dose reduction measures did (61% compared with 16%).
- Reduce contrast volume while maintaining diagnostic quality through the use of lower kVp, dual energy CT, and photon-counting CT.
- Maximize utilization of available contrast and reduce waste multidose ICM vials and automated injectors.
- Establish clear protocols to communicate the status of contrast availability by tracking ICM use across departments and facilities and conducting daily "huddles" and weekly briefings.
Long-term strategies to "future-proof" the department:
- Source ICM from multiple suppliers and production sites.
- Stockpile ICM strategically. Barreto described how, during the crisis, New Zealand was less affected by ICM shortages because its government manages procurement of essential medicines for the entire country and requires its hospitals to hold at least a two-month supply of critical drugs.
- Establish contingency plans for conservation, prioritization, and use of alternative imaging modalities.
- Centralize inventory management to track ICM use across the healthcare network.
- Get involved in regulatory measures, pressing manufacturers to maintain backup production capacity and lobbying for national reserves of ICM and reporting of potential disruptions.
Barreto pointed out that, after the crisis, GEHC added a $30 million production line at its Cork, Ireland, facility; signed a multiyear agreement in Chile for raw iodine; announced an $80 million expansion to its Lindesnes, Norway, facility; and invested a further $138 million in the Cork facility.
Barreto also outlined how managing ICM use and decreasing the imaging exams that require it to carry benefits, including reducing patients' radiation exposure and contrast dose reactions and improving department workflows. She stressed that, going forward, there's a need to assess the long-term effects of the 2022 ICM shortage -- including missed diagnoses from delayed imaging, workflow, and resources impacted by the crisis, any higher costs for using alternative imaging modalities, and also the role of AI in a situation like this one.
