National shortages of personal protective equipment are hitting essential workers across a broad range of sectors.


Hospital workers, police officers, emergency medical technicians, grocery store attendants and nursing home caretakers are having trouble obtaining the equipment on the market that they need to protect themselves.


Shortages have forced health care workers to rewear single-use masks to preserve them, leading many to look toward hyperlocal efforts to make homemade cloth masks, coordinated on Facebook.


People stopped widely needing to sew their own items more than 50 years ago. Why are they now being forced to revert to the seemingly archaic practice, when three months ago, one could buy a surgical mask at the store for $2?


The global supply chain stopped working.


It’s partly a demand problem. For years, Justin Duncan’s EMS department in Washington County used masks sparingly, and rarely needed N95s.


Then the coronavirus came. All of a sudden, the faraway risk was in his backyard. He, like lots of others across the state and the country, started trying to order extra gear online from his distributors. N95 masks were his biggest priority, along with surgical masks and gowns.


Duncan is a Missouri Emergency Medical Services Association board member. If conditions were normal, he wouldn’t need many N95 masks. He said that during typical times, his department would use what he calls a "high level" of personal protective equipment — which would include goggles, a gown, a N95 mask and gloves — around once a week.


"Now I'm running 15 calls for service per day — that’s a minimum of 30 flu masks," he said. "Some calls they can reuse it. Some calls they can't. If they’re at a level where they need an N95, it's reused if it's not soiled."


For each call, his responders wear a surgical mask, gloves and eye goggles. The department is doing precautionary screening for COVID-19 when they’re on the line with callers, asking whether they have a cough or recent exposure to the virus.


If that’s the case, they’ll wear a gown, Duncan said. If the responder will be making contact with someone’s airway, they’ll wear an N95 mask and a face shield.


"We are using a lot more stock than I think we ever dreamed," he said.


The same is happening in most departments across the state, he said. The increased demand has strained Duncan’s distributors, like BoundTree medical, one of the nation’s largest medical supplies distributors to emergency medical departments.


The company, which started noticing major shortages in the middle of March, uses methods to forecast how much demand they’ll have for certain products in a regular year. It orders supplies from a number of different manufacturers to fill that expected need accordingly.


When coronavirus hit, demand quickly exceeded supply. Everyone needed more, all at once.


It was unprecedented, spokesman Beth Scott said.


"We quickly began to run out," she said. "So we went back to our manufacturers, those are people for N95 masks like 3M and Dukal and even Honeywell … and when we go to place our order for those masks, they're already prioritizing hospitals, for example, and they're sending that inventory directly to hospitals."


The company is still getting some supplies, but it’s erratic.


"Six months ago if I ordered PPE, I'd know in 24 hours if it was getting shipped or backordered," Duncan said.


Now, he’ll make an order and won’t be given an ETA. Weeks later, it will just show up at the department. And sometimes nothing comes at all. That applies to all of the distributors he’s been trying to order from, not just BoundTree.


With his current supply, Duncan said he should be okay for the next 30 to 45 days.


"If I have a massive uptick or downtick in call volume, that will change," he said.


A fractured supply chain


The shortages aren’t just due to demand, according to Medline spokesman Jesse Greenberg. Duncan also places orders with the company, which is one of the largest medical equipment suppliers in the country.


The majority of Medline face masks are made in China, Greenberg said, and specifically in Hubei province, which includes Wuhan, the site of China’s largest COVID-19 outbreak.


"Manufacturing was shut down for at least two months there," Greenberg said. "So manufacturing was shut down at a time when the rest of the world's demand for this very product is escalating concurrently. With the increased demand and the shutdown of the biggest link in the supply chain for face masks, you've created now a big hole in the supply chain that we've been struggling to fill."


The company has already shipped 15 million more face masks in 2020 than they shipped in all of 2019, and demand has increased by 300%, Greenberg said. They’ve started sending masks manufactured at their overseas plants by air instead of by cargo, cutting shipment times by three to four weeks.


In Howard County, Boone County’s western neighbor, Sheriff Mike Neal said his department is using kits leftover from the Sept. 11 attacks of 2001.


He doesn’t usually need to order PPE for his officers, so he’s had trouble obtaining equipment on the market, and the state hasn’t prioritized the rural county for supplies.


The 9/11 kits include the type of suit and respirator his officers would need to wear if they were entering a house where COVID-19 was known to be present. He’s put a suit in each of his cars, but for now, his officers are spraying themselves down with Lysol after entering homes.


A local dentist donated a box of surgical masks to the station, a local doctor donated some masks that Neal said resemble dust masks, and a local contractor donated three N95 masks.


On Friday, SEMA provided a shipment of 15 N95 masks to the whole county. That includes Glasgow, Fayette, New Franklin and the Howard County sheriff’s department — four police agencies and a county jail with 15 masks.


"That’s not close to being enough," Neal said.


Neal is hoping for more, and explains that although he doesn’t have enough supplies, he understands other more populated counties with higher numbers of confirmed cases, like Boone, might be prioritized before him.


"It is what it is and you gotta do what you gotta do," he said.


For now, the station is taking people’s temperatures when they come into work and screening people at the door. Officers are wearing masks when they come in close contact with people.


"We’re a third-class county, a rural county," he said. "Our saving grace is that we don't have a big population."


Looking for supplies when there’s none left


There are two ways through which essential workers can obtain PPE if they aren’t able to find any on the market.


Neal got his masks from SEMA, the state’s emergency management agency. Non-medical workers who need PPE go through SEMA. The agency has placed an order on the private market for at least $42 million of PPE, but have only received a very small percentage so far, according to agency spokesperson Caty Luebbert.


Health care workers experiencing market shortages are directed to request new equipment from their regional hospital coordinators, who then file a request with the Department of Health and Senior Services. The DHSS has access to two stockpiles of equipment — the state stockpile and the strategic national stockpile.


Everything in the state’s stockpile is expired by at least five years, according to a March 6 state memo from Paula Nickelson, an administrator in the DHSS’s Office of Emergency Coordination. Since then, the masks have been approved for use by the CDC.


At this point, the stockpile has nearly been exhausted, according to Lisa Cox, DHSS spokesperson. There are still some N95 masks left, she said, but little quantities of anything else.


The department has received three shipments of PPE from the national stockpile, Cox said, after the CDC developed a distribution plan in mid-March to get supplies to states already facing shortages as soon as possible. That depleted the federal PPE stockpile.


At this point, there’s not much the state can do. The supplies aren’t there.


That will change as shipments come in from private partners like Medline, which is doing what it can to expedite the process. But it won’t happen immediately.


Allocation rules


The Jefferson City Medical Group, which provides independent health care services to people in Jefferson City and 12 other locations across the state, many of which are rural family practices, recently had to ask the state for supplies for the first time.


The state and federal governments only dip into national stockpiles in disaster situations. It’s not a regular method of obtaining PPE, Cox said.


The group normally goes through two main vendors to obtain the majority of their equipment, but with those vendors experiencing the national shortages, they’ve had to resort to the state.


For now, they’re just asking for N95 masks. They’ve received a shipment of 48, but with the number of providers the group has, "that was nowhere near what we have requested," said Dawn Cook, the group’s purchasing manager.


"Our goal was to try to get 3,000 of the N95 masks to have in our reserve," Cook said.


The DHSS has a hierarchy through which requests for PPE are filled. Hospitals come first, then EMS departments, then long-term care facilities. Fourth on the list are outpatient clinics, including federally qualified health centers, urgent care centers, and clinics operated by local public health and rural health agencies.


Then comes behavioral health inpatient treatment facilities, and last on the list are outpatient care providers including dialysis centers, physician’s offices and home health.


Companies started putting allocation rules in place when the shortages hit. At BoundTree, shortly after it became apparent that masks were going to run out on the market, individuals started buying masks in bulk and hoarding them.


"We quickly stopped that," Scott said. "We stopped shipping any of our products to individuals or any people that were trying to set up new accounts."


Medline started making similar moves once the company realized the extent of the shortages they were facing. In order to keep things fair with requests so high, the company started selling to companies the same amount of supplies they’d sold to them in previous months.


So, if a medical practice typically ordered 60 N95 masks from a distributor per month, and started filing orders for 600 in March, Medline would allocate 60 masks for them to ensure their basic needs were covered. But that may be all they get.


At Jefferson City Medical Group, that allocation rule was a blessing. Because the group has a surgical center, they were purchasing large bulk orders of PPE before COVID-19 hit, which gave them access to their typical allocation even during the shortages.


But that’s not the case for places like nursing homes, some of which had never filed requests for N95 masks before, but need them as they deal with the populations most vulnerable to the virus.


"So that makes it tough, right?" Greenberg said. "I mean, if you're a facility that typically never ordered certain kinds of face masks, and now you want large quantities of them, you know, it creates a dilemma because now they're competing with large hospital networks who are treating very sick patients in emergency situations."


"Not everybody is getting what they want right now."


Many area nursing homes and hospice companies, like Lenoir Woods, The Bluffs and Compassus Hospice and Palliative Care, have requested cloth masks from local sewing groups to help fill the gaps in supply.


Medline has partnered with the Federal Emergency Management Agency to figure out which systems to prioritize. FEMA is collecting data to ensure that when the company receives shipments of masks and equipment, they are allocated to the areas in the country that are most in need.


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