The lack of essential personal protective equipment (PPE) has been a defining characteristic of the coronavirus pandemic. From the beginning, respiratory protection guidance was driven by shortages of N95 respirators and surgical masks rather than by the well-established standards of infection prevention and control.
SHIFTING GUIDANCE
The first case of coronavirus disease 2019 (COVID-19) in the United States was diagnosed on January 20. By that time, a reservoir of unidentified and asymptomatic cases may already have been established here. In January and February, infection quickly spread in the Seattle area, throughout parts of California, and around New York City.
By early February, case numbers in some locations were increasing exponentially, and PPE supplies, already low, became scarce. Standards of care that once seemed set in stone became fluid and confusing. The routine use of N95 respirators, recommended in the past for the care of patients infected with newly identified respiratory viruses, such as severe acute respiratory syndrome (SARS), was quickly replaced by directives from the Centers for Disease Control and Prevention (CDC) to use N95s only when participating in potentially aerosol-inducing procedures, such as suctioning or intubation. Surgical or "droplet" masks were recommended for all other care of people infected with COVID-19.
As case counts surged, the demand for both types of respiratory protection increased, and shortages worsened. The dearth of PPE led the CDC to post strategies for "optimizing the supply of face masks." The last recommendation says the use of bandanas or scarves might be better than no protection at all when supplies of N95s and surgical masks run out.
A LACK OF ACCESS TO PPE
In individual health care facilities, unclear communication and even frank staff intimidation by leadership contributed to the chaos created by the shortage. In attempts to reduce PPE use, nurses in some hospitals were forbidden to initiate isolation precautions with patients suspected of having COVID-19-a clear violation of infection prevention and control standards. In the New York City area, where rising case counts quickly began to overwhelm hospital capacity, PPE was kept under lock and key. Staff were supplied with one N95 or surgical mask to use for an entire shift or, in some hospitals, for a full week. Across the country, loosely organized groups of people began sewing cotton face masks at home for health care workers to wear. These were used in lieu of reusing paper gear or to cover N95s to decrease contamination during the unprecedented long-term use of these formerly "disposable" items.
As hospital purchasing departments searched frantically for new sources of PPE, some health care leaders tried to control their staff's attempts to protect themselves. In a California hospital, nurses and physicians were told they could be fired if they wore N95s brought from home. An ED physician in Washington State was fired for talking to a reporter about the shortage. A nurse in Newark, New Jersey, was suspended for using GoFundMe to raise money for the purchase of PPE for ICU nurses.
With respiratory protection supplies stretched to the breaking point, the Office of the Inspector General of the U.S. Department of Health and Human Services undertook a nationwide hospital survey to confirm the extent of the problem. The survey documented hospital reports of "widespread shortages of PPE [that] put staff and patients at risk," noting that "hospitals reported conserving and reusing single-use/disposable PPE" and were turning to "new, sometimes unvetted, and nontraditional sources" in their efforts to obtain the needed supplies.
STAFF RESPONSE
Without adequate PPE, hospital staff were torn between their commitment to patients and fears for their own safety. Because COVID-19 infection can be mild or asymptomatic, staff worried that they too might be infected, possibly transmitting the virus to patients or bringing it home to their families. Esther Choo, MD, MPH, started the hashtag #GetMePPE to encourage health care workers to share pictures of their makeshift or overused PPE with their congressional representatives and the vice president.
By early April, after the initial shock of the "new normal" infection prevention and control standards and a month of exploding case counts in some parts of the country, nurses began public protests on hospitals grounds. They spoke with the media and carried signs that ranged from humorous ("Will Work for a New N95") to straightforward ("PleaseProtectEveryone") to deadly serious ("Who Will Care for You When We Are Dead?").
WHAT HAPPENED?
How could the wealthiest country in the world not provide PPE to its workers during a pandemic? The Trump administration seemed not to have fully understood the urgency of the situation. A member of the president's national security team has dismissed as "dated" the Playbook for Early Response to High-Consequence Emerging Infectious Disease Threats and Biological Incidents, a step-by-step guide devised by the National Security Council in 2016 in response to the less-than-optimal global response to the spread of Ebola in 2014 and 2015. The administration might have found its guidance helpful. In an early algorithm regarding immediate issues to address, the playbook asks: "Is there sufficient personal protective equipment for healthcare workers who are providing medical care? If YES: What are the triggers to signal exhaustion of supplies? Are additional supplies available? If NO: Should the Strategic National Stockpile release PPE to States?"
The Strategic National Stockpile of drugs, vaccines, and supplies was created in 1999 to maintain large stores of essential medical supplies, ready to be provided to states and communities within 12 hours of the federal government's decision to do so during an emergency. But despite clear evidence of the PPE shortage and the urgent need for other items, such as ventilators, President Trump initially refused to distribute these supplies. Some supplies were eventually released, and accusations soon followed that politics rather than need directed the process. In some cases, states with small outbreaks received a disproportionate share of supplies. It's been reported that the Strategic National Stockpile had about 30 million N95 respirators available in late February. At least one state (Alabama), reported receiving more than 5,000 rotted surgical masks from the stockpile. Still, the Strategic National Stockpile could never have supplied all of the additional PPE necessary for this pandemic. A 2015 study in Clinical Infectious Diseases by researchers at the National Institutes of Health estimated that in a pandemic in which 20% to 30% of the population is infected, up to 7.3 billion N95 respirators could be needed. (COVID-19 is likely to infect a considerably higher percentage of the population.) But if a rapid escalation of PPE production had been instituted soon after the administration learned of the epidemic on January 3, or even after the first U.S. case was identified on January 20, supplies might now be adequate.
The president could have used the Defense Production Act not only to order private companies to turn to PPE production but also to stop the export of PPE supplies made in the United States, which continued through February, at least. (In January, the U.S. exported masks worth more than $1.7 million to China, and an additional $15.8 million worth of masks was exported in February.) In late March, the federal government signed contracts with five companies to ramp up production of N95 respirators, but as a result of the timelines negotiated, a significant increase in supply is still several months away.
The lack of a coordinated federal response to obtain pandemic supplies left U.S. governors and mayors scrambling to obtain PPE for their health care facilities. The end result was states bidding against each other for the same supplies from the same sources around the world. Prices shot up. By early April, as New York State (the epicenter of the outbreak in the United States) saw COVID-19 cases surge to an apex, staff were still reusing PPE, and supplies had not been replenished. Without help from the federal government, governors began working together in attempts to provide N95s and surgical masks for health care workers in their states.
As we went to press, nurses, nursing assistants, physicians, respiratory therapists, housekeepers, and other essential personnel continued to care for people with confirmed and suspected COVID-19 without adequate protective gear.-Betsy Todd, MPH, RN, clinical editor