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May 12, 2020

Personal Protective Equipment Shortages During COVID-19—Supply Chain–Related Causes and Mitigation Strategies

Author Affiliations
  • 1Infection Control/Hospital Epidemiology, Silverman Institute for Health Care Quality and Safety, Beth Israel Deaconess Medical Center, Boston, Massachusetts
  • 2Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Boston, Massachusetts
  • 3University of Michigan Health System, Ann Arbor
  • 4Center for Global Development, Washington, DC
  • 5INSEAD, Fontainebleau, France
  • 6Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts
JAMA Health Forum. 2020;1(5):e200553. doi:10.1001/jamahealthforum.2020.0553

Since the start of the coronavirus disease 2019 (COVID-19) pandemic, health care systems across the US have reported substantial personal protective equipment (PPE) shortages, compromising their ability to keep health care professionals safe while treating increasing numbers of patients.1 Gloves, face masks, N95 respirators, powered air-purifying respirators, eye protection, and gowns are central to transmission-based precautions. Initial delays in COVID-19 testing increased PPE use, further intensifying demand.

Consequently, some health care professionals have resorted to directly sourcing PPE from personal networks. Infection prevention teams across the country have focused on supply conservation with extended use and reuse protocols. These teams have also collaborated with others (engineers, the maker community, local businesses, and community volunteers) to create new forms of PPE, including respirators and eye protection. At the same time, reports suggest there are overseas suppliers with sizable quantities of PPE who want to supply US health care systems, but logistic issues related to quality, payment terms, and air cargo capacity are among the barriers.

The usual PPE supply chain for health care systems works as follows. Sourcing teams select 2 to 3 large, well-established distributors. Health care systems place orders to selected distributors, and supplies are delivered weekly. The distributors in turn buy from manufacturers or, in many instances, contract third parties to manufacture products that the distributors then sell to the health care system. At present, US-based PPE production is limited, and more than 70% of respiratory protection supplies used in the US are manufactured in China. With large spikes in global demand and drastically reduced production in China during early 2020, major distributors have been unable to fill orders. Some health care systems currently face estimated delays of 3 to 6 months for requested supplies.

Meanwhile, new suppliers and intermediaries have emerged in the PPE supply chain. Some health care systems have resorted to purchasing PPE from unvetted sources without the ability to fully evaluate supplier quality—a task traditionally managed by distribution partners. As such, new PPE clearinghouses run by physician volunteer groups are emerging to connect vetted suppliers with health care system needs.

Why are mainstream distributors—with whom health care systems have had trusted relationships for years—not finding and aggregating these fragmented sources of PPE to fulfill demand? These distributors have dedicated teams specializing in supplier quality assessment and due diligence. Distributors also have more cash on hand to provide the payment terms that PPE suppliers now demand. Why haven’t distributors closed this critical gap?

There are 2 potential reasons. First, distributors would rather supply PPE manufactured in their own factories or contract sites than buy from the open market. Second, distributors are unwilling to pay the higher asking price given concerns that they may not be able to recover added costs. Both reasons demonstrate a fundamental break in the routine PPE supply chain, limitations amplified by COVID-19. The frightening reality is that the routine US PPE supply chain was not designed with the primary objective of protecting health care professionals. Rather, it was designed to fulfill demand while focusing on efficiency and price. While this supply chain can fulfill normal demand, it cannot meet unexpected increases that occur during a public health crisis, such as the current COVID-19 outbreak or the 2009 influenza A outbreak.

The Department of Health and Human Services’ Strategic National Stockpile (SNS) and state stockpiles are mechanisms to provide additional PPE in emergencies. Requesting PPE from SNS involves a discussion among local, state, and federal officials through established protocols. Normally, PPE in the SNS can be dispatched from storage locations to the requesting locations within 24 to 36 hours of approval.

Getting adequate PPE allocation from the SNS has been a challenge during the COVID-19 pandemic. First, overall stock in the SNS was much lower than previous estimates of what would be needed to protect health care personnel in the event of a severe influenza pandemic.2 Second, lack of transparency regarding PPE and other inventory in the SNS as well as the logic behind the allocation of its limited supplies has hampered credibility.

Teams have demonstrated ingenuity in mitigating current PPE shortages by launching new PPE sourcing initiatives, such as GetUsPPE.org, ProjectN95.com, and Operation Masks; developing volunteer initiatives to reclaim PPE from other uses; working with engineers to use 3-dimensional printers for PPE; and finding new ways to decontaminate and reuse PPE. All of these testify to this resourcefulness. Plans to conserve PPE have also changed care delivery and include the use of electronic consults and virtual visits, extended dwell infusions, and batching or self-administration of medications. However, solving extreme PPE shortages cannot be the primary work of health care professionals and infection prevention teams.

Developing a robust PPE supply chain must be the first order of business for health care administrators, distributors, manufacturers, and government agencies. Health care professionals and infection prevention experts also must actively participate in reshaping the supply chain.

Stockpiles of at least 3.5 billion N95 respirators and 500 million surgical masks should be maintained at federal levels, and additional stock should be held at state and local levels.2,3 A transparent system should routinely report stock, requisitions, depletions, and allocation rules. Furthermore, during a pandemic, PPE supplies from federal and state level stockpiles, together with commercial supply, should flow seamlessly into health care systems without burdening clinicians and hospital administrators with the complex task of matching PPE supplies from different sources to fulfill demand. Ideally, a PPE supply chain visibility platform would maintain accurate, real-time inventory data held in locations managed by federal and state agencies and distributors. Health care professionals and infection prevention teams, in partnership with medical supply chain management, should collectively develop order orchestration rules that can act as the guiding principle for how different sources of stock would be allocated.

Health care professionals should ask their hospital administrators for a careful re-evaluation of medical supply distributor contracts. Contracts with distributors should have clearly defined service-level clauses for large demand surges. Health care systems should also require distributors to demonstrate supply preparedness plans and geographic diversity in their production base.

Provisions in the Coronavirus Aid, Relief, and Economic Security (CARES) Act could be used to provide the needed financial capital for large-scale PPE supply chain reform, including investment in automated production lines with excess capacity to withstand surges in demand and resolution of information gaps in the medical supply chain with integrated information systems. The time to act on these recommendations is now.

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Article Information

Open Access: This is an open access article distributed under the terms of the CC-BY License.

Corresponding Author: Preeti Malani, MD, MSJ, University of Michigan Health System, F4135 University Hospital South, 1500 E Medical Center Dr, SPC 5226, Ann Arbor, MI 48109-5226 (pmalani@umich.edu).

Conflict of Interest Disclosures: None reported.

Bauchner  H, Fontanarosa  PB, Livingston  EH.  Conserving supply of personal protective equipment—a call for ideas.   JAMA. Published March 20, 2020. doi:10.1001/jama.2020.4770PubMedGoogle Scholar
Carias  C, Rainisch  G, Shankar  M,  et al.  Potential demand for respirators and surgical masks during a hypothetical influenza pandemic in the United States.   Clin Infect Dis. 2015;60(suppl 1):S42-S51. doi:10.1093/cid/civ141PubMedGoogle ScholarCrossref
Patel  A, D’Alessandro  MM, Ireland  KJ, Burel  WG, Wencil  EB, Rasmussen  SA.  personal protective equipment supply chain: lessons learned from recent public health emergency responses.   Health Secur. 2017;15(3):244-252. doi:10.1089/hs.2016.0129PubMedGoogle ScholarCrossref
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    1 Comment for this article
    Big Data-driven personal protective equipment stockpiling framework under Universal Healthcare for Disease Control and Prevention in the COV
    Kevin Sheng-Kai Ma, DDS, MSc |
    Big data analytics has improved healthcare by analyzing electronic medical records, socio-demographic information, and environmental factors [1]; moreover, its tracking roles in emerging infectious diseases including the coronavirus pandemic have been discussed [2]. In countries with single-payer universal healthcare systems (UHS), claimed data of payers could be an abundant source for analytics. On the other hand, compulsory social distancing, coupled with mass masking, has been widely adopted as strategy for non-specific symptoms at early stage COVID-19 [3]. We propose that analytics based on proper concatenation of databases may prevent supply shortages for personal protective equipment (PPEs).

    Taking Taiwan as
    an example, cloud computing-based healthcare databases within the UHS has alleviated the integration between primary care providers and hospitals, as well as reduced the cost of tracking procedure. Applying the same logistics to PPE allocation would allow PPE providers to manage the distribution of surgical masks on a real-time basis, and recognize the mask holders per insurance or passport number [4]. With the help of data analysis, combining artificial intelligence and cloud technology, public health policy-making could be practicable. Thus when it comes to the implementation cost of epidemic prevention policies, Taiwan authorities adopt low stringent level strategies compared with other high income countries, but still have achieved epidemic control in the early outbreak [5].

    After the 2003 severe acute respiratory syndrome outbreak, Taiwan CDC (TCDC) started transferring registered real-time infectious disease data to this established monitoring system, where PPE stockpiling platform was practiced. Therefore, prior to the official recognition of COVID-19 outbreak [2], PPE databases were subsequently concatenated by UHS to manage resource allocation and logistics when several cases were identified. Establishment of this application programming interface for mask-selling pharmacies under UHS required data transfers as well as managerial issues including governance and ownership, which interdepartmental communication was efficient within UHS. Specifically, the tracking system expands the healthcare informatics system that pharmacists are familiar with, which user friendly interfaces for these PPE providers and consumers help expedite processes in an efficient manner [4]. UHS and TCDC have also promoted the system to increase the distribution channels, which government offices may also allot masks to lessen the burden on healthcare providers.

    Since masks alone aren’t effective without combining infection-control measures [6], we recommend to utilize such integrative platform for the maintenance of more PPE stockpiles, including critical infection-control equipments, so as to reduce iatrogenic COVID-19 exposure.


    [1] Kevin Vigilante, Steve Escaravage, and Mike McConnell. Big Data and the Intelligence Community — Lessons for Health Care. N Engl J Med 2019; 380:1888-1890
    [2] C. Jason Wang, Chun Y. Ng, Robert H. Brook. Response to COVID-19 in Taiwan: Big Data Analytics, New Technology, and Proactive Testing. JAMA. 2020; 323(14): 1341-1342.
    [3] Megan L. Ranney, Valerie Griffeth, and Ashish K. Jha. Critical Supply Shortages — The Need for Ventilators and Personal Protective Equipment during the Covi