War with Coronavirus and Lack of “Armor” for Medical Personnel

On Wednesday, President Donald Trump said the United States is at “war” with the coronavirus and that he’s “in a sense, a wartime president.” We agree. And that’s even more reason to address the glaring fact that healthcare workers are serving on the coronavirus frontlines without sufficient armor to protect themselves. The safety of these men and women should rank among the top priorities in the campaign to stop the pandemic. 

When Secretary of Defense Donald Rumsfeld met with troops during the Iraq war in 2004, he was put on his back heels by a challenging question from a scout with the Tennessee National Guard. “Now why do we soldiers have to dig through local landfills for pieces of scrap metal and compromised ballistic glass to up-armor our vehicles, and why don’t we have those resources readily available to us?,” asked Specialist Thomas Wilson which drew immediate cheers from many of the 2,300 troops assembled.

The conservative writer, Giselle Donnelly wrote in the Washington Examiner that the exchange was “a reality check for an arrogant and isolated Beltway bigwig.”  

It would be good, to say the least, for a senior Trump administration official to have the confidence to hold a similar public meeting with the pandemic’s frontline medical staff. But in the meantime, consider some facts.

In Wuhan, China, hospital staff made up a significant portion of the early COVID-19 infections, according to preliminary research, and a similar pattern appears to be emerging in Italy and now the United States. In the coming days and weeks, many more medical workers will be hospitalized or quarantined themselves due to the shortage of personal protection equipment (PPE) to keep them safe. 

This is not simply a moral issue of what the country owes these public servants. Without any guarantee that healthcare workers will be protected, calls like the one by Governor Andrew Cuomo for retired health professionals to come to the frontlines will be harder to meet. What’s more, efforts to flatten the curve to protect the capacity of the healthcare system may not work if the healthcare workforce is being hollowed out from within.

Baseline risks and protocols (pre-coronavirus)

Healthcare workers are accustomed to assuming some risk of occupational exposures to disease.  Anyone who enters a health profession knows that dangers are involved in caring for patients who may have communicable diseases. 

The CDC and the Occupational Health and Safety Administration strive to minimize these risks by establishing standard infection control protocols for work in healthcare settings (for example, gloves for blood draws, followed by handwashing and proper sharps disposal). Under normal circumstances, higher risk  procedures such as intubations, cough inductions, bronchoscopies or administration of anesthesia, healthcare workers may need to add additional elements of PPE to avoid splashes into their eyes, nose, mouth, onto broken skin, or other types of contact with contaminated fluids. Some specific illnesses require protections beyond standard measures to prevent spread in healthcare settings. In these cases, additional transmission-based precautions are needed, sometimes in combination. These include equipment and practices to prevent disease spread via droplets (Droplet Precautions), airborne particles (Airborne Precautions), or pathogens that adhere to surfaces (Contact Precautions)

To appreciate the level of caution that is typical for American healthcare settings under normal circumstances, pre-coronavirus, it’s helpful to consider how low the risks of  transmission of certain pathogens actually are. Consider HIV/AIDS as an example: the HIV transmission rate for an accidental needlestick is 0.3 percent, and for a mucous membrane exposure, 0.09 percent. By the end of 2016, an estimated 1.1 million people were living with HIV infection in the United States, out of approximately 325 million people amounting to a prevalence of a fraction of 1 percent. This means that personal protective equipment is routinely used by health workers to prevent infections that are already unlikely to occur — far less likely than the current risk healthcare workers face of acquiring the virus that causes COVID-19.

Coronavirus risks and procedures

Now consider the situation with the ongoing pandemic, in which the prevalence of the disease is increasing at an explosive rate inside the United States and throughout the world.

Ease of transmission

Current evidence suggests that a significant amount of viral transmission results from contact with asymptomatic or mildly symptomatic patients. What’s more, patients are not the only ones in healthcare settings who may transmit disease. Doctors, nurses, environmental service workers, administrative assistants, and others come into frequent and close contact with one another, particularly since social distancing is nearly impossible to institute under these circumstances. Coughing and sneezing can transmit the virus if particles come into contact with someone else’s eyes, nose, and mouth, and so can contact with contaminated surfaces where the virus lasts for days, according to a new study in the New England Journal of Medicine. (The same study finds the novel virus is detectable in the air for up to three hours, but there is still no evidence that it can be transmitted that way.) 

Elissa Schechter-Perkins, a professor of Emergency Medicine at Boston University School of Medicine, told Just Security: 

We are practicing social distancing outside the hospital exactly because we can’t tell who has COVID 19 and is able to transmit it to us. People can infect others before they have symptoms. Stay 6 feet away from your friend, because he might be infected and give it to you. We don’t have that luxury in the hospital, where we are caring for your infected friend for his non-COVID related problem, being told to stand within spitting distance, and ignore that one cough or sneeze.”

Prevalence among patients in medical care facilities

Emergency rooms across the United States are filling up with patients and beginning to exceed capacity. The number of infections is skyrocketing in many locations throughout the United States, even while testing lags behind in its ability to document this. Epidemiologist and professor Marc Lipsitch of Harvard University, one of the world’s foremost experts on infectious disease transmission, has estimated that as many as 40-70 percent of the world’s adult population may become infected with the virus that causes COVID-19. A CDC model reportedly predicts that between 160 million and 214 million people in the United States could be infected, a range that includes different assumptions about the characteristics of the virus.

Consider the example of New York City. This week city officials issued a briefing, “Everyone in New York should assume that they have been in contact with COVID-19.” That makes sense. But the city officials’ evidence-based guidance — that any New Yorker might be infected with the virus that causes COVID-19 — contradicts what healthcare workers on the frontlines are being told, which is that they should wear PPE only in certain instances with particular at-risk patients. 

Guidelines versus frontline realities

To protect healthcare workers from acquiring the virus that causes COVID-19, the CDC and the Occupational Health and Safety Administration (OSHA) together describe the following PPE for healthcare workers: 

Personal Protective Equipment

Healthcare workers must use proper PPE when exposed to a patient with confirmed/suspected COVID-19 or other sources of COVID-19 (See OSHA’s PPE standards at 29 CFR 1910 Subpart I).

CDC and OSHA recommend that healthcare workers wear:
●  Gowns
●  Gloves
●  National Institute for Occupational Safety and Health (NIOSH)-certified, disposable N95 or better respirator
●  Eye/face protection (e.g., goggles, face shield)

Shortages on the frontlines

There isn’t enough equipment to care for the coming wave of known and symptomatic COVID-positive patients. 

Prior to the COVID-19 pandemic, the CDC anticipated possible shortages in the event of a pandemic and developed guidelines for use of N95 masks in the face of shortages. The guidance envisioned extended use and reuse of the respirators but with conditions including: (1) some respirators can function “for 8 hours of continuous or intermittent use” and (2) a respirator must be discarded “following close contact with any patient co-infected with an infectious disease requiring contact precautions.” But even those conditions are not being met in medical settings today due to shortages. “Many doctors around the country said they are being given just one [respirator mask], to use indefinitely, and they spray it down with Lysol or wipe it off, not knowing whether that will help preserve it,” according to a New York Times report.

Hospital officials at some locations are now telling staff to refrain from using PPE in many hospital settings even though PPE would likely lower their risk of exposure. For example, a major health care system in a midwest metropolitan center issued a memorandum to staff on Friday, saying that gloves should be used for patients, including confirmed COVID-19 patients, only for blood draws and handling bodily fluid. “Gloves are NOT needed when touching intact patient skin such as when doing vitals, assessments and most other routine tasks,” the memorandum obtained by Just Security states (emphasis in original). However, current CDC guidance for COVID-19 infection control procedures states that healthcare personnel should “put on clean, non-sterile gloves upon entry into the patient room or care area.” The hospital system’s memorandum says, “these are unprecedented times, which require unprecedented procedures.”

Other medical settings are restricting staff use of other PPE including masks. Chair of the department of surgery at Lancaster General Health, in an email to staff obtained by Just Security, wrote that wearing masks and gloves in situations other than caring for patients on special contact precautions “only feeds into the fear and hysteria” and “wastes resources.” A physician from Orange County, California, who asked not to be identified but gave Just Security permission to quote their statement, posted a question in a private Facebook group where physicians gather to share coronavirus information, “Is anyone else’s hospital prohibiting use of your own N95 masks? They are saying no personal masks allowed and they will provide ‘appropriate PPE’ (surgical masks) as per CDC guidelines. They say they don’t want to incite anxiety and fear. Shouldn’t it be our right to protect ourself if they aren’t?”

The CDC website has been updated to include guidance about what healthcare providers should do in the absence of standard PPE (while noting that the efficacy of such measures is unknown). The new CDC guidance makes reference to home-made masks, and even items such as a “bandana” or “scarf.” This is completely unprecedented in an American healthcare setting — masks in a hospital under normal circumstances are essentially as available as paper towels. What’s more, the CDC’s website now contains a section entitled, “Strategies for Optimizing the Supply of Facemasks,” and “When No Facemasks Are Available, Options Include.” Safety guidelines in these cases are reflecting what is available, rather than what is safest.

That guidance is being applied in practice. Jeffrey Silberzweig, chief medical officer for the Rogosin Institute, which has nine facilities in the New York City area and provides dialysis for 1,400 patients with end-stage kidney disease, told the Washington Post that his centers will run out of supplies in three to five days and plan to start using face shields along with bandanas as a substitute for masks. Dr. Eric Dickson, head of UMass Memorial told the Boston Globe that they have started thinking about last-resort options including cutting up paper gowns to create makeshift face masks. 

Schechter-Perkins told Just Security, “I have been trained to take care of patients with emergent problems. I am excellent at caring for people with strokes, with heart attacks, with mangled extremities, with cockroaches in their ears. At no point in my education was I taught how to make a mask to protect myself from a potentially deadly virus. I have spent time practicing medicine in third world countries and seen similar home-made protective gear. I never imagined that our supply chain in the US would involve similar measures.”

The Trump Administration’s Foreknowledge

What aggravates the problem in the war against the coronavirus is that administration officials knew ahead of time of these shortages. 

Tim Morrison, John Bolton’s former deputy at the National Security Council, has touted the work he did including a report titled the National Biodefense Strategy of 2018. What Morrison does not mention is that the 2018 report identified the need to “establish manufacturing surge capacity” for PPE in anticipation of a pandemic — a statement on paper that was never implemented by the administration.

On Thursday, the New York Times broke the story of a simulation exercise conducted by the Trump administration, named “Crimson Contagion.” The months-long tabletop exercise was designed to prepare for future contagious disease outbreaks and provide lessons learned. The result of the exercise, contained in an internal draft report in October 2019 and marked “Draft Do Not Distribute,” included a section titled “resources.” That section foregrounded the lack of PPE preparedness in the event of a global pandemic. It is startling to read that section now (our highlights included):

Jeremy Konyndyk, former director of USAID’s Office of US Foreign Disaster Assistance, in an interview with one of us on the Deep State Radio podcast, explained that the administration should have anticipated the risks due to the work of the presidential presidential transition teams, continued awareness of the national security establishment, and National Intelligence Council reports on a regular basis. “Even if you had no awareness of these sorts of risks prior to the beginning of January of this year,” Konyndyk added, “the moment that the world saw what was happening in Wuhan, China in mid to late January, that should have shaken everyone out of whatever torpor they might’ve been in, because we were seeing hospitals in a modern metropolis with a sophisticated health system go down, become completely overwhelmed by the explosion of this virus. And there was no good reason watching that to think it couldn’t happen here. And there was every reason to think it could.” 

In the same DSR podcast, Juliette Kayyem, former Assistant Secretary for Intergovernmental Affairs at the Department of Homeland Security, said, “We failed to take the time or the time that we were given, those six or eight weeks while China was trying to contain it or isolate it, to really prepare ourselves, our communities, our hospitals, with the kind of information and materials and assets that they would need.”   

Schechter-Perkins spoke about her reflections about the current crisis in an email to Just Security:  

These are terrifying times. We see pictures of our colleagues in China and Italy caring for their patients in hazmat suits, and we don’t have those available to us.

We are constantly exposed to patients that might be infected. I have taken care of multiple patients that presented to the hospital for what seems to be an unrelated problem, and then during the course of their ED visit their status changes, and it turns out they are likely ill with COVID-19, and we have all gotten exposed because we weren’t initially taking precautionary measures. There isn’t enough PPE for us to use for every patient that we see.

I have developed an elaborate system to try to avoid bringing the contagions I am exposed to at the hospital home to my family. It involves trashbags labeled as “contaminated” (in which I toss dirty scrubs and white coats immediately after a shift) and “clean” (for the clothes I change into before leaving) as well as “contaminated but bleach cleaned” for things like my stethoscope, pager, and ID). I shower the minute I walk in the door after work. I am making the routine up as I go along, but I think I am separating exposed from not exposed fairly well. In the days before COVID 19, this routine didn’t exist.

We frontline physicians are incredibly frustrated. These shortages were anticipated, and maneuvers should have been taken by the federal government in time to avoid them. Other nations have been able to respond to this situation more effectively than we have in the United States. So we are forced to try to care for our patients while putting ourselves at risk. We are being treated as though we are expendable.    

An emergency medicine physician practicing in Ohio told us, “How can the United States of America, with the largest GDP in the world, sends its doctors, nurses and healthcare providers in to fight this disease without the most basic protective gear they need?” “How did we just ignore all warnings and do nothing since January?” the physician added.

* * *

Wartime presidents and their staff have faced uproar when American service members were dying due to avoidable shortages of troop safety equipment. And whistleblowers who have brought attention to those kinds of bureaucratic failures have been valorized. A similar outrage is happening now. Medical personnel will fall prey to the virus in increasing numbers, which will lead to a cascade of many more casualties within the American population as the healthcare workforce breaks down. We can’t sustain these losses on the frontlines and hope to win the war.

 

Photo credit: from Twitter (@rae_gartland, @CorneliaLG, @queenofironyRN, @AmySilvermaRN, @MusicCityEMCCM)

 

Filed under:
About the Author(s)

Melissa Bender, MD MPH

MD, Harvard Medical School; MPH, Harvard T.H. Chan School of Public Health. Follow her on Twitter (@mbendernyc). 

Ryan Goodman

Co-Editor-in-Chief of Just Security, Anne and Joel Ehrenkranz Professor of Law at New York University School of Law, former Special Counsel to the General Counsel of the Department of Defense (2015-2016). Follow him on Twitter (@rgoodlaw).