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The healthcare and pharmaceutical vulnerability emerging from the new Coronavirus outbreak
Full text linkWith a constantly increasing number of
infected people world-wide,
1 the
COVID-19 (2019-nCoV)
outbreak risks
becoming a pandemic emergency, and for
this reason, on 28 February 2020 the
WHO upgraded the global risk of the
coronavirus outbreak to ‘very high’.2 As
many studies have shown, in the first
phase of the onset of 2019-nCoV
there is
an exponential curve of infection with a
reproduction number (R0) ranging from 2
to 5,3 an indication that the spread of the
virus cannot spontaneously decrease. A
significant reduction in these R0 values can
possibly be achieved by implementing
specific containment actions, according to
the results of a study of the evolution of
the infections detected in China .4 The
spread of the virus is favoured by its ability
to be transmitted by asymptomatic
patients,5 a particularly grave consideration,
given that the currently estimated
incubation period extends from 2 to 12
days.6 Furthermore, the easiest screening
methods based on the execution of a nasopharyngeal
swab displayed false negative
results in both asymptomatic and symptomatic
patients,7 making it more complex
to intercept possible infected subjects,
especially before a clinical manifestation
of the infection.
Since its onset in Europe, the 2019-nCoV
emergency has been addressed
by implementing social containment
measures. This is particularly true in Italy,
the first European country struck by an
important 2019-nCoV
outbreak. On 4
March 2020 the national government
approved a series of important social
limitation measures including the closure
of schools and universities, and the quarantine
of exposed persons; it also urges
residents to avoid crowded events, and
has set in motion contact tracing efforts.
Considering that containment of the
spread of the virus seems very unlikely, the
restriction measures adopted by Italy seem
more focused on dilution of the epidemic
peak over a wider timeframe. As reported
in a scientific paper,8 the first outcomes
of these measures would be to buy time
for preparations in the healthcare system,
to avoid overwhelming the healthcare
system, and to enable better management
of 2019-nCoV
infected patients.
This seems essential for the Italian
health system, as, since 2009, more than
€37 billion have been cut in healthcare
costs and hospital beds have been reduced
to 3.2 per 1000 inhabitants, compared
with a European average of 5 per 1000
inhabitants.9 The number of hospital beds,
in particular, seems to be a crucial issue
in management of the 2019-nCoV
emergency,
which is characterised by the need
for hospitalisation in intensive care units
for >15% of infected patients.10 For this
reason, the Italian government has set up
a 50% increase in the number of beds in
these critical hospital areas and a patient
distribution agreement between healthcare
institutions aimed at avoiding the
collapse of some hospitals affected by a
greater influx of infected patients.11
Delaying the peak of the epidemic could
also be useful for a subsequent introduction
of some pharmacological interventions.
At present, there is no defined
therapeutic protocol to be used on patients
with 2019-nCoV,
and the drugs that
have shown significant efficacy in some
studies,12 13 such as remdesivir, lopinavir/
ritonavir, and hydroxychloroquine, are
currently undergoing phase 3 clinical trials
( ClinicalTrials. gov register). Another aid
that could take place later is the possible
availability of an effective vaccine capable
of blocking the virus spread. Currently
>15 vaccines are in the pipeline12 but
none are foreseen to be available before
the third quarter of 2020.14
Another important aspect of the global
emergency is certainly linked to its social
impact. Our life dynamics are deeply
influenced by the containment measures,
and for the first time in the 21st century
we are facing a health emergency on a
global scale. However, while solutions
such as remote smart working, video calls
and e-commerce
allow us to carry on with
our lifestyle to some degree, other aspects
of our society such as our global and
connected economy and crucial import
supply chains could be deeply affected.
The supply of medicines is a crucial
issue when facing a global health emergency.
We have become used to hearing
news about shortages of hand sanitiser and
facemasks dictated by so-called
‘panic-buying’,
but a much more serious threat
is the potential shortage of drugs. Locally,
shortages can be linked to increased
demand and difficulties in transport in
the areas most affected by the emergency.
Globally, there could be a remarkable
reduction in the production capability of
pharmaceutical manufacturing facilities
where active pharmaceutical ingredients
(API) are produced, as work is interrupted
to update sanitisation procedures for the
infrastructure and production rooms, or
as scientists, managers and line workers
fall ill with the virus. Moreover, it is well
known that drug makers rely heavily on
ingredients made in Chinese factories.
According to the CEO of Sanofi, 60%
of the world’s API is made in China15
and this could cause supply problems
as the virus’ disruption of the Chinese
economy continues. In fact, a drug was
recently added to the US Food and Drug
Administration’s (FDA’s) Drug Shortages
List specifically because of the effects of
the coronavirus. The manufacturer notified
the FDA that the shortage is due to
problems with the production of an active
pharmaceutical ingredient at a site affected
by coronavirus.16 However, this news is
only the tip of the iceberg, as according
to some sources17 the monitoring of the
risk of shortage related to the 2019-nCoV
would concern “About 150 prescription
drugs—including antibiotics, generics and
some branded drugs without alternatives”.
Unfortunately, not only drug supplies
may risk shortfalls: the production of
medical devices may falter as well. Indeed,
as reported by the FDA, “The agency
reached out to 63 companies with a total
of 72 facilities in China that make essential
medical devices”. FDA Commissioner Dr
Stephen Hahn said that “several of these
facilities in China are adversely affected”
by the epidemic and that their workforces
have taken a hit from the outbreak,
including employees being quarantined.16
These worrying developments provide
an opportunity to discuss economic
realities that create vulnerability in our
healthcare sector. It is becoming clear that
production backup sites are needed to
ensure adequate supplies, even in the most
1Clinical Pharmacy, ISMETT, Palermo, Italy
2Experimental medicine and Public health, University of
Camerino, Camerino, Italy
Correspondence to Dr Carlo Polidori, Experimental
medicine and Public health, University of Camerino,
Camerino 62032, Italy; carlo. polidori@ unicam. it
Editorial
Eur J Hosp Pharm: first published as 10.1136/ejhpharm-2020-002278 on 18 March 2020. Downloaded from http://ejhp.bmj.com/ on March 19, 2020 by guest. Protected by copyright.
2 Leonardi D, et al. Eur J Hosp Pharm Month 2020 Vol 0 No 0
Editorial
complex situations. Also, the fact that,
before this crisis, our healthcare system
had not developed a strategy to deal with
potential epidemics, could provide an
opportunity to reflect on where to act to
be prepared in the event of similar or even
more serious health threats.
Contributors DL and PP wrote the paper and CP
revised it.
Funding The authors have not declared a specific
grant for this research from any funding agency in the
public, commercial or not-for-
profit
sectors.
Competing interests None declared.
Provenance and peer review Not commissioned;
internally peer reviewed.
© European Association of Hospital Pharmacists 2020.
No commercial re-use.
See rights and permissions.
Published by BMJ.
To cite Leonardi D,
Polidori C, Polidori P. Eur J Hosp Pharm Epub ahead of
print: [please include Day Month Year]. doi:10.1136/
ejhpharm-2020-002278
Eur J Hosp Pharm 2020;0:1–2.
doi:10.1136/ejhpharm-2020-002278
ORCID iDs
Carlo Polidori http:// orcid. org/ 0000- 0001- 6946- 8638
Piera Polidori http:// orcid. org/ 0000- 0001- 8496- 9908
References
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4a5e- b992- 2478023c6d01. htm
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Temporal transition of nesting activities in the digger wasp Bembecinus tridens (Hymenoptera, Crabronidae).
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individual females in Northern Italy, in order to quantify frequencies, duration, and sequence of the nesting activities. Wasp
females dug unicellular (in one case multicellular) nests preferably on oblique surfaces. Nest digging occurred mainly in the
morning, while definitive nest closing was performed only in the afternoon, and nests were frequented by the owners for
3.52 days on average. One to eight nests were dug by single females in rapid succession in the area observed, revealing a
rapid dispersion towards other sites. Provisioning and non-provisioning (control) flights were positively correlated and
occurred mainly in the late morning. A number of orientation flights followed most exits from the nests but was higher at the
end of nest digging. Nest closing lasted more at the end of provisioning and at the end of digging. Provisioning began more
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injections, continuous lateral brain ventricle infusion of high doses of N/OFQ increased
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