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Editorial
March 28, 2020

Sourcing Personal Protective Equipment During the COVID-19 Pandemic

Author Affiliations
  • 1Dr Livingston and Dr Berkwits are Deputy Editors and Dr Desai is Fishbein Fellow, JAMA
JAMA. 2020;323(19):1912-1914. doi:10.1001/jama.2020.5317

As the coronavirus disease 2019 (COVID-19) pandemic accelerates, global health care systems have become overwhelmed with potentially infectious patients seeking testing and care. Preventing spread of infection to and from health care workers (HCWs) and patients relies on effective use of personal protective equipment (PPE)—gloves, face masks, air-purifying respirators, goggles, face shields, respirators, and gowns. A critical shortage of all of these is projected to develop or has already developed in areas of high demand. PPE, formerly ubiquitous and disposable in the hospital environment, is now a scarce and precious commodity in many locations when it is needed most to care for highly infectious patients. An increase in PPE supply in response to this new demand will require a large increase in PPE manufacturing, a process that will take time many health care systems do not have, given the rapid increase in ill COVID-19 patients.

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    8 Comments for this article
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    Lessons learned from the shortage of PPE.
    Gladwin Das, MD | Retired from the University of Minnesota
    The PPE shortage crisis is self inflicted. The companies that supply these items have contracted with largely Chinese manufacturers and are in fact middlemen.

    Does the US military outsource its manufacturing of ammunition, missiles, tanks, aircraft to China ? PPE is not less important.

    Short term strategy : Cloth/fabric gowns, masks , drapes etc. These can be easily manufactured in the USA in large quantities.

    All US hospitals/clinics should physically have a 2 week supply of fabric gowns, masks, caps, drapes as an emergency supply for disruptions of the supply chain.

    Long term strategy : All
    PPE must be manufactured in the USA.

    It is time Congress passed a law to enable this. The AMA and ANA leadership need to demand permanent solutions from the President and Congress. We need to drive the process and not be mute bystanders.This should never ever happen again.
    CONFLICT OF INTEREST: None Reported
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    PPE and Testing
    William Harrell, MD | Private physician
    Some of my commercial lab test submissions have returned within three days and others have been up to nine days or more. Hence, unusable for screening---only useful for statistics.

    An office PPE order to a major medical supplier over a month ago was cancelled. What few we have to screen febrile patients were obtained from members of the community.

    Our large medical building has ruled that we must not perform tests in the building at all. Tests performed on the grounds outside are only allowed with special permission on a limited time basis. County and
    City screening sites turn sick patients away when they are overwhelmed on a daily basis.
    CONFLICT OF INTEREST: None Reported
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    Multi-threaded PPE Sourcing Pipeline
    Sophia Boettcher, BSCS | PPEforHCP.org
    In less than a week since posting a comment on the preceding “Call for Ideas” (regarding conservation of PPE) I was able to implement this very idea and singlehandedly outsourced 20,000 masks and level-iib isolation suits from China as well as leverage a coalition of local sewers (using the Deaconess/Providence templates). I worked with Momentum.Space to develop 3D printed shields and also partnered with a bus company for hand sanitizers using the FDA’s temporary guidance on hand sanitizers. I am currently working on re-outfitting clothing factories to produce face masks per the FDA’s guidelines.

    It can be done. As
    a group of volunteer doctors and engineers we are busily responding to hospitals across the country now to send them free PPE and to map shortage outbreaks. There is friction/absence of willingness among administrators to actually set up this pipeline themselves however—understandably due to the burden of dealing with the crisis on the ground.

    Thousands of Americans across the country want to help and we’ve been able to quickly find traction. Hospitals need to proactively reach out and not penalize HCPs for doing so, especially now.

    REFERENCES

    https://www.fda.gov/regulatory-information/search-fda-guidance-documents/enforcement-policy-face-masks-and-respirators-during-coronavirus-disease-covid-19-public-health

    https://www.fda.gov/media/136289/download

    https://jamanetwork.com/journals/jama/fullarticle/2763590

    https://www.deaconess.com/How-to-make-a-Face-Mask

    https://www.deaconess.com/How-to-make-a-Face-Mask

    https://budmen.com/

    https://www.prusa3d.com/covid19/

    https://www.medscape.com/viewarticle/927541

    https://www.medscape.com/viewarticle/927590

    https://www.medscape.com/viewarticle/927528

    https://www.wsna.org/about/press-area/2020/wsna-state-ment-on-firing-of-dr-ming-lin-and-silencing-of-nurses-and-doctors
    CONFLICT OF INTEREST: None Reported
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    Need for expert consulation and direction
    Kristin Morrison, MD | Hotel Dieu Hospital, Kingston, Ontario
    Thank you for a concise summary of the issues and your concluding statements regarding the inappropriateness of frontline workers having to source or create our own solutions. However in the midst of this current crisis, having access to a diverse group of experts who could review and respond to the most common questions and suggestions would save countless hours of searching and experimentation by those desperate individuals. Having this information centralized and readily available would be an essential service to us all. For example - the information provide about the effects of different methods of decontaminating N95 masks was invaluable, however I am still unclear as to how many of these methods work to kill off pathogens other than the SARS-CoV-2 virus. So what might be appropriate for someone working in a medical COVID ward - such as hanging a mask for 4 days, might not be appropriate for someone working in ICU where there is a higher risk of other secondary infections etc. I live in Canada so probably less concern re litigation - but surely in the current crisis, this could be managed in a way to limit liability especially if we are able to get expert consensus on best practices in desperate situations.
    CONFLICT OF INTEREST: None Reported
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    Simple ideas that may help during COVID-19 pandemic
    Ali Al-Shanqeeti, MD | Saudi Arabia
    We are all watching this pandemic unfold with massive impact on human lives. Desperate times call for desperate measures. The CDC recommendations during situations of crisis (recently reviewed in a perspective published online in New England Journal of Medicine) are an example of how to suggest ideas even if based on "thin" evidence.

    Therefore I would like to share with everyone this idea that may help with protecting healthcare workers (and potentially the public) especially since the world is now facing a potential shortage of N95 masks and other PPE items. Here is the summary of the idea
    and the suggested steps:

    1. Viruses (including the corona family of viruses) can be deactivated when they come in contact with surfaces covered with sodium chloride (table salt) . This can be explained by physical destruction of virus during recrystallization of coated salts. When the salt-coated surface is exposed to virus aerosols, salt crystals below the aerosol droplet dissolve to increase osmotic pressure to virus. Due to evaporation, the salt concentration of the droplet significantly increases and reaches the solubility limit, leading to recrystallization of salt. As a consequence, virus particles are exposed to increasing osmotic pressure during the drying process and are physically damaged by crystallization (1) .
     
    2. Many of the widely available consumables have pore sizes that are significantly smaller than the size of COVID-19 virus which is 60-140 nm in diameter (2). For example; the 3M Micropore surgical tape has pores that are 2nm in diameter. Therefore, the virus is not expected to pass through the pores of the 3M micropore surgical tape acting as a physical barrier to the virus.

    The implications for PPE conservation: 

    a) Healthcare workers must wear gloves at all times. These gloves must be sprayed with hypertonic saline (HTS) immediately after wearing them. The wet gloves are then allowed to air dry (few to several minutes) thus creating a layer of dried salt crystals on the gloves surfaces. This way, if a virus containing droplet / droplets come(s) in contact with the gloves surfaces; the salt crystals on these surfaces will dry the virus particles and inactivate the virus (see 1 above) rendering them non-infective.

    b) Similarly both sides of a regular surgical mask are sprayed with HTS and allowed to air dry. A standard surgical mask spayed with HTS and allowed to air dry is to be used by all healthcare workers all the time. The open peripheral edges of the mask are taped to the face of the care provider to seal the mask to the face. This way, the virus particles will not pass through the sides of the mask (tape pores are smaller than the size of the virus) and the virus will be inactivated on both the outer and inners surfaces of the mask (because of the salt crystals)

    This is an idea that in my opinion carries no additional risk, is cheap, affordable and one will lose anything trying it in such desperate times. It can also be adopted for public use.

    REFERENCES 

    1. Quan, F., Rubino, I., Lee, S. et al. Universal and reusable virus deactivation system for respiratory protection. Sci Rep 7, 39956 (2017). https://doi.org/10.1038/srep39956

    2. Cascella M, Rajnik M, Cuomo A, et al. Features, Evaluation and Treatment Coronavirus (COVID-19) [Updated 2020 Mar 20]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-.Available from: https://www.ncbi.nlm.nih.gov/books/NBK554776/
    CONFLICT OF INTEREST: None Reported
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    Plastics Manufacturing
    Trevor Orrick |
    We are a manufacturer of plastic components in California. We are on the strategic manufacturing list. We make other non-medical items. We have done research and can build tooling in 7 days to manufacture 1000+ plastic face shields a day. We just don't know if there is a need for these? We know there are different types of these, disposable versus reusable, closed or open on sides. If there is a need and we could get some direction we are all ears.

    Thanks

    Trevor Orrick
    805 471
    3951
    trevor@trevororrick.com
    CONFLICT OF INTEREST: None Reported
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    In use in Seattle: DIY plastic isolation gown for <$0.50
    Scott Veirs, Marine science | Seattle
    We are between contingency and crisis modes in Seattle.

    Until official gowns can be provided to health care providers, please share with your colleagues this guide for making a DIY isolation gown from plastic sheeting and a clothes iron.

    My wife's pediatric clinic in Seattle is using these after running out of $1 rain ponchos from Amazon. Each of these costs less than 50 cents to make and a takes my teenagers a couple of minutes to make.

    Step-by-step guide (aka as an Instructable)  is at https://www.instructables.com/id/DIY-Plastic-PPE-Gown/
    CONFLICT OF INTEREST: None Reported
    Challenging the principle of ‘reasonably practicable’ by the flooding of counterfeit and fake face masks during the COVID-19 pandemic
    Simon Ching Lam, PhD, RN, FHKAN | Squina International Center for Infection Control, School of Nursing, The Hong Kong Polytechnic University.
    Thank you for a concise and comprehensive summary of the captioned and the insightful conclusive statements. As in other regions in the world, this shortage of personal protective equipment (PPE) (i.e., gloves, face masks, air-purifying respirators, goggles, face shields, respirators, and gowns) has been unfolding in Hong Kong as well as Mainland China on mass and/or social media online. Such shortage added pressure to the hospital administrators and infection control officers to re-adjust infection control guidelines so they were “reasonably practicable” for different “job tasks” (1). These adjustments (e.g., prudent use of PPE, and extended use of PPE) were generally based on World Health Organization’s interim guidance regarding rational use (2). As a consequence, in this case, it is noteworthy that the quality of PPE should be up to described/documented standard because there is no room to allow the increased infection risk due to fake material.

    For the quality of face masks, it was reported that hundreds of thousands of fake masks appeared in the markets because coronavirus depletes the global supplies (3). With reference to ASTM F2299-03 (4), our centre has established a particle filtration efficiency (PFE) system to preliminary assess the filtration performance of face masks by the use of artificial aerosols 0.3 micron and 1.0 micron under the flow rate of 15 L/min. We have received 66 brands masks with different sources and countries from many regional enquires. Surprisingly, in the midst of this current pandemic, we have come across about 45% low quality face masks (i.e., PFE of 1 micron range from 44%-94%). Some face masks (~4.5%) were the counterfeit of some international well-known brands on mask manufacturers, where the difference in PFE was 48.97% (fake) versus 99.99% (genuine). About 35% of face masks claimed an ASTM level 1 standard (i.e., PFE > 95% on 0.1 micron, with provided certification or printed description on box) demonstrated insufficient filtration performance on even 0.3 micron (range = 6.74% - 94.4%). Furthermore, 1.5% of sampled masks were made of tissue paper as the inner filter that was totally un-waterproofed. Indeed, the PFE of a mask is unable to be estimated by inspection. However, most of the hospitals do not have time and equipment to test the purchased face masks before use. This result is alarming and adds great uncertainty to the infection prevention and control in both clinical and community settings towards the COVID-19 outbreak. This may also turn the infectious pandemic to a new hybrid disaster (natural and man-made events) mode (5), particularly the application of ‘reasonably practicable’ now.

    References:
    1. Health and Safety Executive (HSE). (n.d.). Risk management: ALARP at a glance. Accessed April 02, 2020. http://www.hse.gov.uk/risk/theory/alarpglance.htm
    2. World Health Organization. Rational use of personal protective equipment for coronavirus disease (COVID-19): Interim guidance, 27 February 2020. Accessed April 02, 2020. https://apps.who.int/iris/handle/10665/331498
    3. Daragahi B. ‘Total disregarded for people’s lives’: Hundreds of thousands of fake masks flooding markets as coronavirus depletes world supplies. 25 March, 2020. The Independent. Accessed April 02, 2020. https://www.independent.co.uk/news/health/coronavirus-face-mask-fake-turkey-medical-supply-shortage-covid-19-a9423426.html
    4. ASTM F2299 / F2299M-03. Standard Test Method for Determining the Initial Efficiency of Materials Used in Medical Face Masks to Penetration by
    CONFLICT OF INTEREST: None Reported
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