www.frontlineppenow.org

As cases of COVID-19 escalate around the country, physicians and other healthcare workers (HCWs) are facing severe shortages of personal protective equipment (PPE). This shortage is already a major crisis and will place an insurmountable strain on the health system of this country as cases continue to rise and more people require hospitalization for complications of COVID-19.

As a result of this shortage, recommendations from the Centers for Disease Control (CDC) for appropriate PPE for HCWs on the frontlines have shifted. This shift does not come in response to overwhelming evidence, rather to a supply chain issue.

As quoted directly from the CDC website: “PPE recommendations for the care of patients with known or suspected COVID-19: Based on local and regional situational analysis of PPE supplies, facemasks are an acceptable alternative when the supply chain of respirators cannot meet the demand."..."When the supply chain is restored, facilities with a respiratory protection program should return to use of respirators for patients with known or suspected COVID-19."(1)

These statements in no way suggest that droplet precautions are adequate, supported by the statement that as soon as the supply chain has been restored, we should go back to using N95 respirators. As a result of these recommendations, many hospitals have taken the CDC recommendations to mean that facemasks are the preferred PPE, rather than a less desired (and potentially less safe) alternative. They have thus rationed respirators to be made available only for procedures, such as intubation and bronchoscopy, during which the virus is more likely to become aerosolized. This is putting our HCWs in tremendous danger of contracting and spreading COVID-19, which is unacceptable in the country with the most expensive health care system in the world.

The evidence that droplet precautions are acceptable is lacking. CNN recently published an article titled “Health care workers getting sicker from Coronavirus than other patients”.(2) This statement is corroborated by data from a Harvard Study in China that suggested HCWs were at a 20% increased risk of severe infection compared to the general public. This risk decreased once the Chinese implemented full gear: protective suit, medical goggle, face shield, N95 mask and gloves – following this change there were no further reports of infected HCWs.(3)

The debate is still ongoing as to whether or not COVID-19 can be transmitted via droplets vs. aerosols, yet as we speak, HCWs around the world continue to get infected, end up in critical condition, and die while using “appropriate PPE”. According to an ahead of print New England Journal Article on aerosol and surface stability of COVID-19, the virus can be detected up to 3 hours after aerosolization.(4) According to Dr. Milton, professor of environmental health at University of Maryland, “you cannot tell epidemiologically between something aerosol transmitted by weak sources and large droplet spray”, and he suspects the capability of long distance transmission will be dependent on the degree of symptoms.(5) Considering the mortality risk and lack of data to support a step-down to surgical masks, N-95 masks should continue to be the standard PPE for care of COVID-19 patients.

As a physician, I do not know how long it takes to make an N95 mask, but I do know how long it takes to train a physician, a nurse practitioner, a physician’s assistant, a respiratory therapist or nurse. We are the supply chain that needs to be protected. Our friends from Italy have described the loss of infected HCWs as a critical hit to an already strained system. Infected HCWs are of no benefit to patients – in fact, they pose a serious risk.(6) They not only endanger the health of their colleagues, families, and communities, they also serve as a vector to infect the most vulnerable among us – the patients they care for. China, Italy, and S. Korea have more experience with this virus than we do and are taking the protection of their HCWs seriously. In France, Dr. Benjamin Davido, Infectious Diseases and Clinical lead for COVID-19, explains the importance of protecting HCWs against the severity of the illness, by using FFP2, the European equivalent of N95 masks.(7) “If we don’t do all we can to protect them (HCWs), they will quickly transition from providers to patients… Governments must support private-sector manufacturers in providing N95s and other equipment to HCWs.”(6)

This letter serves to urge our government, industry, media and general population, to assist HCWs in obtaining immediate access to critical PPE, including N-95 masks. Our HCWs are already on the front lines, taking care of patients without appropriate protection, and our COVID cases and we are nowhere near the peak. Many hospitals are already running out of protective supplies. (NY Times, 3/9/2020) Recommendations to protect HCWs should not be based on what’s available; availability should be based on what is necessary. We urge the government to access the Strategic National Stockpile, and to utilize both the public and private sector to immediately increase production of PPE supplies. In addition, we urge our hospital systems to maintain the highest level of PPE standard for our HCWs, and demand the supply of N-95 masks.

Sincerely,

Dr. Milla J. Kviatkovsky

Dr. Constance Chace

Dr. Supraja Thota

https://www.frontlineppenow.org/

#frontlineppenow

#getmeppe

References:

1) https://www.cdc.gov/coronavirus/2019-ncov/infection-control/control-recommendations.html

2) Howard and McLaughlin, ‘Health care workers getting sicker from coronavirus than other patients,’ expert says, CNN Health, March 12,2020

3) Xihong Lin, ‘Analysis of 25,000 Lab-Confirmed Cases in Wuhan: Epidemiological Characteristics and Non-Pharmeceutical Intervention Effects, Department of Biostatistics and Department of Statistics, Harvard University and Broad Institute

4) N Doremalen et Al, 2014, Aerosol and Surface Stability of HCoV-19 (SARSC-CoV-2) compared to SARS-CoV-1, New England Journal of Medicine

5) Souchery, ‘Unmasked: Experts Explain Necessary Respiratory Protectin for COVID-19’, Center for Infectious Disease and Research Policy, Feb 13, 2020

6) Osterholm and Olshaker, ‘Health-Care workers are the front-line warriors against coronavirus. We must protect them’, The Washington Post, Feb 14, 2020

7) Duqueroy, COVID-19: Advice From a French Doctor on the Frontline, Medscape, 3/16/2020