Shortages related to the 2019–20 coronavirus pandemic

**Medical material and other goods shortages caused by the 2019–20 coronavirus pandemic** are a major issue of the ongoing pandemic. The matter of pandemic-related shortage has been studied in the past and has been documented in recent events. On the medical side, shortages of personal protective equipment such as medical masks, gloves, face shields, gear, sanitizing products, is also joined by potential shortage of more advanced devices such as hospital beds, ICU beds, oxygen therapy, mechanical ventilations and ECMO devices. Human resources, especially in term of medical staff, may be drained by the overwhelming extent of the epidemic and associated workload, together with losses by contamination, isolation, sickness or mortality among health care workers. Territories are differently equipped to face the pandemic. Various emergency measures have been taken to ramp up equipment levels such as purchases, while calls for donations, local 3D makers, volunteer staffing, mandatory draft or seizure of stocks and factory lines have also occurred. In some cases, medical workers have been ordered to not speak about these resources shortages.

## Tests

### Diagnostic tests

#### Reagents

In Ireland and the UK, in late March and early April, reagent shortages limited the number of tests. By March, insufficient amounts of reagent has become a bottleneck for mass testing in the EU and UK and the US. This has led some authors to explore sample preparation protocols that involve heating samples at 98 °C (208 °F) for 5 minutes to release RNA genomes for further testing.

In UK, on 1 April the government confirmed that a total of 2,000 NHS staff had been tested for coronavirus since the outbreak began, but Cabinet Office Minister Michael Gove said a shortage of chemicals needed for the test meant it was not possible to screen the NHS's 1.2 million workforce. Gove's statement was contradicted by the Chemical Industries Association, which said there was not a shortage of the relevant chemicals and that at a meeting with a business minister the week before the government had not tried to find out about potential supply problems.

#### Swabs

A feared shortage of swabs in Iceland was averted when stocks were found to bridge the gap until more arrived from China. Shortages arose in the US, though one manufacturer increased production to 1 million swabs per day. Shortages also arose in the UK, but were resolve by 2 April.

## Personal protective equipment

Masks, gloves, closes, and sanitising products have been in shortage. A survey of medical personnel pointed out at the lack of proper equipment as the main issue in their current efforts, with 90% claiming they went to work without the proper equipment.

Given that the global supply of personal protective equipment (PPE) is insufficient, the World Health Organization recommends minimising the need for PPE through telemedicine, physical barriers such as clear windows, allowing only those involved in direct care to enter a room with a COVID-19 patient, using only the PPE necessary for the specific task, continuing use of the same respirator without removing it while caring for multiple patients with the same diagnosis, monitoring and coordinating the PPE supply chain, and discouraging the use of masks for asymptomatic individuals.

### Sanitising products

Hand sanitiser was largely out of stocks in many areas, causing price gouging.

### Protective gear

In the United States, some nurses at one New York City hospital have been reported as wearing garbage bags as an alternative to unavailable protective clothing.

### Facial masks

#### Early epidemic in China

As the epidemic accelerated, the mainland market saw a shortage of face masks due to the increased need from the public. It was reported that Shanghai customers had to queue for nearly an hour to buy a pack of face masks which was sold out in another half an hour. Some stores are hoarding, driving up prices and other acts, so the market regulator said it will crack down on such acts. The shortage will not be relieved until late February when most workers return from the New Year vacation according to Lei Limin, an expert in the industry.

On 22 January 2020, Taobao, China's largest e-commerce platform owned by Alibaba Group, said that all face masks on Taobao and Tmall would not be allowed to increase in price. Special subsidies would be provided to the retailers. Also, Alibaba Health's "urgent drug delivery" service would not be closed during the Spring Festival. JD, another leading Chinese e-commerce platform, said, "We are actively working to ensure supply and price stability from sources, storage and distribution, platform control and so on" and "while fully ensuring price stability for JD's own commodities, JD.com has also exercised strict control over the commodities on JD's platform. Third-party vendors selling face masks are prohibited from raising prices. Once it is confirmed that the prices of third-party vendors have increased abnormally, JD will immediately remove the offending commodities from shelves and deal with the offending vendors accordingly." Other major e-commerce platforms including Sunning.com and Pinduoduo also promised to keep the prices of health products stable.

#### Rest of the world

Shortage in single-use medical mask and field reports of reuse lead to the question of which process could properly sanitise these PPE without altering their filtering capacity. In 2006, 156 million masks were added to the US Strategic National Stockpile in prevision of a flu pandemic. After they were used against the 2009 flu pandemic, neither the Obama administration nor the Trump administration renewed the stocks.

FFP2 masks can be sanitised by 70°C vapor allowing reuses. Use of alcohol is discouraged since it alters N95 mask microfibers' static charge which helps filtration. Chlorine is also discouraged since its fumes may be harmful. Authors are warning against reuses by non-professionals, pointing out that even the best scored methods can degrade the mask if not performed properly.

Following N95 masks shortages, volunteers created 3D printed "NanoHack" alternative. This printed mask allows to use hand-cut surgical mask as fine-particle filters. Vacuum bags can be sewn into masks.

A Singaporean study found no contamination on mask after brief care to COVID19 patients, suggesting masks could be reuse for multiple patients cares.

On April 1st, US's Strategic National Stockpile was nearly emptied.

French regional representative complained that ordered masks cargo were hijacked by americans paying 3 times the price.

#### Do it yourself masks

Given the scarecity of masks and ambiguity on their efficiency, individuals and volunteers have started to produce masks for themselves or for others. Various designs are shared online to ease creation.

### Medical face shield

File:Visor frame v10.stl
Reacting to shortage of face shield, volunteers from the maker community with 3D printing abilities initiated an effort to produce face-shields for hospitals' staff. On 24 March, while the epidemic was expanding, popular French 3D maker and YouTuber Heliox announced her willingness to produce face-shields for free building upon another maker's design. She was quickly contacted by local hospitals, health centres and other medical professionals asking for rapid delivery of face shield. The visible popularity of her initiative caused other 3D makers to join the effort and offer their help in other regions to connect health facilities with nearby makers.

On 30 March, the The New York Times published a video on COVID-19-related shortages and healthcare workers' DIY solutions.

**3D printed medical face shield created in response to COVID19's medical shortage**

## Medical care devices

The availability of critical care beds or ICU beds, mechanical ventilation and ECMO devices generally closely associated with hospital beds has been described as a critical bottleneck in responding to the ongoing 2019–20 coronavirus pandemic. The lack of such devices dramatically raises the mortality rate of COVID-19.

### Oxygenation mask

Popular snorkeling masks have been adapted into oxygen dispensing emergency respiratory masks via the usage of 3D printed adapters and minimal modifications to the original mask. According to Italian laws relative to medical cares where the project has occurs, usage by the patient requires a signed declaration of acceptance of use of an uncertified biomedical device. The project provides the 3D files for free, as well as 2 forms to register hospitals in need and 3D makers willing to produces adapters.
France main sportwear and snorkeling masks producer Decathlon has locked down is mask sales in order to redirect them toward medical staff, patients and 3D makers.

### Intensive care beds

See also: List of countries by hospital beds
Both rich countries and developing countries have or will face intensive care beds shortages, but the situation is expected to be more intense in developing countries due to lower equipment levels.

In early March, the UK government supported a strategy to develop natural herd immunity, drawing sharp criticism from medical personnel and researchers. Various forecasts by Imperial College COVID-19 Response Team, made public on 16 March, suggested that the peak number of cases in the UK would require between 100 and 225 CCBs / 100,000 inhabitants, if proper mitigation or no mitigation strategies are put into force, respectively. These requirements would both exceed the UK's current capacities of 6.6–14 CCB / 100,000 inhabitants. In the best case scenario, the peak caseload would require 7.5 times the current number of available ICU beds. Around 16 March, the UK government changed trajectory toward a more standard mitigation/suppression strategy.

In France, around 15 March, the Grand Est region was the first to express the scarcity of CCB limiting its handling of the crisis. Assistance-publique Hôpitaux de Paris (AP-HP), which manages most hospitals in the French capital area (~10 million inhabitants), reported the need for 3,000–4,000 ICUs. Current capacity is reported to be between 1500 and 350, depending on the source.

In France, given shortages of ICU hospital beds in Grand Est and Ile-de-France regions, severe but stable patients with ARS and breathing assistance have been moved toward other regional medical centers withing France, Germany, Austria, Luxembourg or Switzerland.

### Mechanical ventilation

Mechanical ventilation have been called *“the device that becomes the decider between life and death”* for COVID-19 patients, due to COVID19 being a respiratory disease sending all about 5% of detected cases to rely on the device now in shortage. Ventilators shortage is endemic in the developing world. In case of shortage, some triage strategies have been previously discussed. One strategy is to grade the patient on dimensions such as : prospects for short-term survival ; prospects for long-term survival ; stage of life-related considerations ; pregnancy and fair chance. The frequent 15 to 20 days duration of the intubation to recover is an important factor in the ventilator's shortage.

An important way of reducing demand for ventilators is the use of CPAP devices as a first resort. For this reason CPAP devices themselves have become a scarce item.

#### Officials assessments

In the 2000s, the US CDC estimated a shortage of 40~70,000 ventilators in case of pandemic influenza. From this assessment resulted *Project Aura*, a public-private initiative to design a frugal, 3,000 US$ mechanical ventilator, simple to mass-produce, and able to supply the Strategic National Stockpile. Newport Medical Instruments was granted the contract, designing and prototyping (2011) the frugal ventilators to CDC officials, and expecting to later profit from the product by moving into the private market were other competing devices were sold for 10,000US$. On April 2012, US Health and Human Services officials confirmed to the US Congress that the project was on schedule to file for market approval in late 2013, after which the device would go into mass-production. In May 2012, US$12 billion-worth medical conglomerate Covidien, a top actor of the mechanical ventilation market, acquired Newport for 100 million US$. Covidien soon asked to cancel the *Project Aura* contract since it wasn't profitable enough. Former Newport executives, government officials and executives at rival ventilator companies suspect Covidien acquired Newport to prevent the frugal 3,000 ventilator design from disturbing its profitable ventilation operation. Covidien has merged in 2015 into Medtronic. *Project Aura* looked for and then signed a new contract with Philips Healthcare. In July 2019, the FDA signed for 10,000 units of their Trilogy Evo portable ventilator, to be delivered to the SNS by mid-2020.

On 25 March, Andrew Cuomo made a detailed 1-hour COVID-19 press conference, emphasising an expectation of a severe shortage of ventilators, and their importance in sustaining life in severe COVID-19 cases. Cuomo said New York state would ultimately need about 30,000 ventilators to handle the influx, while having only 4,000 as of 25 March; on the 27th, President Trump expressed doubt about the need, saying "I don’t believe you need 40,000 or 30,000 ventilators," and resisting calls to force businesses to produce them. Later on the 27th, the President acceded to calls to assist states in ventilator procurement, using the Defense Production Act; fears remain that procurement will not happen in time to prevent severe shortages.

#### Industrial suppliers

In Europe, the company Löwenstein Medical producing 1500 ICU-level ventilators and 20,000 home-level ventilator per year for France alone, pointed out of the current high demand and production shortage. Based in Europe, all their components are European and not relying on Chinese's supply chain. As for production ramp up, it was suggested to increase the production of home-level ventilators, more basic and which can be assembled in half an hour yet able to support patients through acute respiratory distress syndrome. The current bottleneck is mainly a question of qualified human resources. In business as usual, ICU-level ventilators are to be renewed every 10 to 15 years. Due to the coronavirus pandemic, Germany and other European countries have started to take control over the company's supply.

In China, local manufacturers are racing to answer the demand.

Medtronic made ventilator design specifications publicly available.

#### Hackers

See also: Open-source ventilator

3D makers have been working on various low-cost alternative ventilation devices or adaptations.

Anaesthetist Dr. Alan Gauthier from Ontario, Canada, turned one single-patient ventilator into a nine-patient device thanks to a 2006 YouTube video by 2 doctors from Detroit. The method uses T-shaped tubes to split airflow and multiply the number of patients provided with respiratory support.

In Ireland, volunteers started the *Open Source Ventilator Project* in collaboration with medical staff.

In Italy, local journalist and journal director Nunzia Vallini of the *Giornale di Brescia (Brescia Daily)* was informed that nearby Chiani hospital was running out of valves which mix oxygen with air and are therefore a critical part of reanimation devices. The valves supplier was itself out of stock leading to patient deaths. Vallini contacted FabLab founder Massimo Temporelli, which invited Michele Faini, an expert in 3D print manufacturing and a research and development designer at Lonati SpA to join a 3D printing effort. When the supplier didn't wish to share the design's specifics, they reverse-engineered the valves and produced a limited not-for-profit series for local hospitals. In order to satisfy biomedical requirements that can withstand periodic sanitation, Lonati SpA used their SLS 3D printers to print about 100 valves in Nylon PA12. Faini and Temporelli still acknowledge the limitations of their production: 3D printing not being able to reach the quality and sterilised context of the original valves and manufacturing process. Contrary to rumors online, the valves don't cost US$10,000 each and the original manufacturer did not threaten to sue the 3D printers team.

Hackers of the *Ventilator Project* have brainstormed to propose to re-purposing CPAP machines (sleep-apnea masks) as ventilators, hacking single ventilators to split air-flow and treat multiple patients, and using grounded airplanes as treatment facilities to leverage their one-oxygen-mask-per-seat infrastructure. Engineers familiar with devices design and production, medical professionals familiar existing respiratory devices and lawyers able to navigate FDA regulations if the needs arise are key participants among the 350 volunteers involved. The central avenue of exploration is to ditch away the most advances features of modern mechanical ventilation, which includes layers of electronics and patients monitoring systems, to focus solely on assisted respiration by pressured airflow. The group is, by example, looking for an old Harry Diamond Labs "emergency army respirator" model to study. While hopeful they will be able to submit viable and mass-producible design, several questions linger at this later levels: mass production line, FDA approval, personnel training, personnel availability, and eventually actual needs on the battlegrounds to come.

An MIT team has designed an emergency ventilator.

### ECMOs

Extracorporeal membrane oxygenation are devices able to replace both the lungs and the patient's heart. As of 6 February 2020, the medical community was encouraged to set up criteria for ECMO patients triage.

## Facilities

As Wuhan's situation worsened and in order to assist the overwhelmed Central Hospital of Wuhan and Dabie Mountain Regional Medical Centre, China built two emergency field hospital within a few days: the Huoshenshan Hospital and Leishenshan Hospital. The hospitals were progressively phased out in March 2020.

On 23 March, Lieutenant General Todd T. Semonite, Chief of the U.S. Army Corps of Engineers, signaled an ongoing effort to lease existing facilities such as hostels, college dormitories, and a larger hall to temporarily convert them into medical facilities.

On 16 March, French President Emmanuel Macron announced a military hospital would be set up in the Grand-Est region, to provide up to 30 ICU beds. The hospital was being tested 7 days later.

By 8 March, Lombardy had created 482 new I.C.U beds answers to the initial shortage. Lodi's ICU director reported that every single square metre, every single aisle of the hospital had been repurposed for severe COVID-19 patients, increasing ICU beds from 7 to 24. In Monza, 3 new wards of 50 beds each were opened on 17 March. In Bergamo, gastrology, internal medicine, neurology services have been repurposed.

In the UK almost the entire private health stock of beds was requisitioned, providing an additional 8,000 beds. Three Nightingale hospitals were created by NHS England, with the military, to provide an additional 10–11,000 critical care beds, another 1,000 bed hospital created in Scotland, and a 3,000 bed hospital at the Principality Stadium in Cardiff. Temporary wards were constructed in hospital car parks, and existing wards re-organised to free up 33,000 beds in England and 3,000 in Scotland for COVID-19 patients. A hanger at Birmingham International Airport was converted into a 12,000 body mortuary.

## Health workers

The factors in health worker shortage are several. First, the excess demand due to the pandemic. Second, the specialised nature of care of the critically ill and the time taken to train for new methods of working to prevent cross-contamination, in some cases with new types of protective equipment (PPE). The third factor is the loss of staff to the pandemic, mostly because they are self-isolating with symptoms (which may be unrelated) or because a household member has symptoms, but also because of long term effects of the disease, or death. This last case applies across the health system and makes it harder to draw staff from non-COVID health workers.

Mitigations being used include recruiting military and sports medics, final-year doctors in training, private sector staff, and re-recruiting retired staff and those who have moved from the medical sector.

For non-medical roles staff have been recruited from other sectors.

### Isolation and trauma

See also: Mental health during the 2019–20 coronavirus pandemic
#### China

As for China, medical staff are self isolating from families and under high emotional pressure.

Psychological trauma is expected among medical professionals.

### Sickness and death

At least 50 Chinese doctors died.

In Lombardy, Italy, with the mid-March 2020 outbreak, medical staff reported high level of sick staff. In Lodi, doctors from other services have been called to attend Covid patients. In Cremona, the number of patients entries was three times the usual while services were running with 50% of their staff. On 12 March, 8% of Italy's 13,382 cases were health workers. It was also reported that between 5 and 10% of deaths were medical staff. On 17 March, one of the largest hospital of the Bergamo region ran out of ICU beds, patients were flown to other regions by helicopter.

About 14% of Spanish cases are medical staff.

## Groceries

Some daily goods have seen shortages, mainly due to panic buying.

## Others

In France, due to closed borders and the impossibility for foreign seasonal worker to come over, the government's Minister of Agriculture called for jobless volunteers to contact strawberries farms and help collect the harvest for the usual minimal wage.

Laboratory mice are being culled, and some strains are at risk of shortage due to lockdowns.