Wednesday, April 01, 2020

Shortages, confusion and poor communication complicate coronavirus preparations

Feb 26. 2020
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By The Washington Post · Lena H. Sun, Christopher Rowland, Lenny Bernstein · NATIONAL, WORLD, HEALTH · 

Major U.S. hospital systems are burning through their supplies of specialized masks needed for a widespread epidemic of coronavirus, in part because federal protocols call for them to be thrown out after a single use in practice sessions, federal officials have told health-care leaders.

Some hospitals have just a week's inventory of the N95 face masks, which filter out 95 percent of all airborne particles, even as a top official with the Centers from Disease Control and Prevention warned Tuesday that spread of the virus here now appears inevitable.

At a tense invitation-only briefing held last week, the Department of Health and Human Services offered few answers to health system leaders trying to prepare for wider spread of coronavirus, according to participants. Parts of the presentation were obtained by The Washington Post. 

The possible mask shortage is one of countless critical issues that federal, state and local officials and health care providers are confronting as the U.S. posture on the covid-19 crisis shifts from keeping the virus out of the country to mitigating its impact here. Already, coordination and communication problems among the various parts of the public health apparatus are beginning to cause difficulties, according to providers on the front lines.

HHS also said 60 percent of large-chain pharmacies are already unable to meet demand at stores for the masks, technically known as "respirators."

"Personal protective equipment is not what you think about day-to-day" at most hospitals, said Lauren Sauer, who oversees preparedness and response for Johns Hopkins Medicine and the Johns Hopkins University system. "What is the plan for allocation of scarce resources? Is it going to be who has the most face time" [with HHS officials] who gets the most supplies?"

CDC spokesperson Kristen Nordlund said the agency's guidance has to be flexible. "We can't be too specific, because it might not be something a health department or hospital can do, or it might not fit their needs at the moment."

Many of those involved in the response have been preparing for weeks. But if there was any doubt among them, the CDC eliminated it Tuesday by openly asking Americans to prepare for the disruption that widespread transmission of the virus would cause in their communities.

"Ultimately we expect we will see community spread in the United States," said Nancy Messonnier, director of the CDC's National Center for Immunization and Respiratory Diseases, who described a breakfast table conversation she had with her own children. "It's not a question of if this will happen but when this will happen, and how many people in this country will have severe illnesses."

Messonnier outlined scenarios she said Americans now must contemplate, including school and day-care closings, increased teleworking and limiting, postponing or canceling mass gatherings. She did not mention lockdowns like the one that has paralyzed central China, the epicenter of the outbreak that has killed more than 2,400 people and sickened more than 80,000. The United States so far has 57 known cases and no deaths.

Hospitals and public health officials on the leading edge of the U.S. mitigation strategy have been preparing for weeks.

In San Antonio, for example, Metro Health Director Dawn Emerick said she is rounding up 30 recreational vehicles that might be used to house infected people and looking for a place to put them. The city already has 11 people who were evacuated from the Diamond Princess cruise ship and Wuhan, China in isolation rooms in a special facility, but Emerick anticipates greater need as tests of more individuals come in.

At one point, Emerick halted the RV plan when federal officials told her that sick people evacuated from Asia to nearby Lackland Air Force Base would be sent to a facility on a former Army base in Anniston, Alabama. But when officials in that state objected, the RV plan was resurrected, she said.

"What we've been trying to do at the local level is look at alternatives that are safe, that are away from the community," Emerick said.

At the sprawling NYU Langone Health system in New York, which has nearly 1,700 inpatient beds at six facilities, doctors are working to prevent patients from swamping hospitals with minor respiratory complaints and crowding out patients who may need more intensive care.

They are ramping up messaging that tells people how to arrange online appointments with providers and other alternatives, said Michael S. Phillips, chief hospital epidemiologist for the system.

Similarly, hospitals in Washington State are discussing triaging patients in parking lots and "and if it's really bad, people can get a drive-through screening in their car," said state Health Director John Wiesman.

The Hopkins health system also has contingency plans to use nonmedical spaces, such as cafeterias, a children's play area and ambulance ramps to treat respiratory patients. The ambulance ramp is set up to accommodate a tent, has heated water, gas lines and electricity.

Health systems need more specific guidance, Sauer said. "We've maxed out on our capacity to prepare without additional pieces of information. People would really like to see something concrete from the federal government, like say, 'it's a pandemic, it's time to shift strategies to mitigation'."

Guidance from the CDC on use of face masks has too many caveats said Russell Faust, medical director of Oakland County, Michigan's health department. Under current federal guidelines, after a mask is adjusted to form a seal over an individual's mouth and nose during a test run, it should be thrown away. 

CDC recommended that providers "consider" extended use or repeat use of the respirator, he said. "They're waffling big time," he said. "That is a little concerning. We hope that at some point, someone will say, 'Here's what you do when you run out of N95 respirators."

Faust already has developed a workaround. If coronavirus arrives, Oakland County personnel will put surgical masks over N95s, protecting the underlying mask somewhat so it can be used again.

NYU is already working to conserve "personal protective equipment" - full body moon suits, masks, face shields and other gear - for a shortage that Phillips considers inevitable. Many masks used in U.S. hospitals come from Hubei province in China, where the outbreak began. And when production in China resumes, equipment surely will be reserved for use in that country, he said. About 65 percent of N95 respirators are manufactured outside the continental United States, in China and Mexico, according to HHS data.

NYU is urging health-care personnel to re-use moon suits now to help preserve inventory for later. That is appropriate, for example, in treating patients with tuberculosis, he said. Face masks can be used again by the same individual, especially after practice sessions, he said.

"We are really looking carefully at how we're utilizing [protective equipment] and I think every hospital in the United States is girding for these kind of shortages," he said.

While some hospitals have as many as 14 weeks worth of masks on hand, the overall situation is grim. India, Taiwan, and Thailand also have halted or limited exports as they brace for spikes in demand in their own countries.

Anticipating a surge in need, California's state officials have ordered 300,000 masks to distribute to hospitals and clinics on an emergency basis, hoping to add to the 20,000 currently in state stockpiles. Officials would not say where they hope to find that many masks.

Health care systems nationally have about two weeks of supply left on hand, said Soumi Saha, senior director of advocacy at Premier Inc., a large group purchasing organization that serves 4,000 hospitals.

Normally, an average of 2 million masks per month is used in the United States, Premier said. That rises to 4 million per month during a typical flu season. 

Two domestic manufacturers that use raw material from the United States - 3M and Prestige Ameritech - are ramping up production but are not expected to be able to satisfy demand of 4 million masks a month until April, Saha said. 

"I don't think hospitals can sort of buy their way out of this problem. It is not a bidding war for N95s," said Amy Ray, director of infection prevention for the MetroHealth System in Cleveland. "The supply is the supply and prudence is necessary to preserve the stock that we have.''

 

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