Now the U.S. Has Lots of Ventilators, but Too Few Specialists to Operate Them

A patient was placed on a ventilator in a hospital in Yonkers, N.Y., in April.

As record numbers of coronavirus cases overwhelm hospitals across the United States, there is something strikingly different from the surge that inundated cities in the spring: No one is clamoring for ventilators.

The sophisticated breathing machines, used to sustain the most critically ill patients, are far more plentiful than they were eight months ago, when New York, New Jersey and other hard-hit states were desperate to obtain more of the devices, and hospitals were reviewing triage protocols for rationing care. Now, many hot spots face a different problem: They have enough ventilators, but not nearly enough respiratory therapists, pulmonologists and critical care doctors who have the training to operate the machines and provide round-the-clock care for patients who cannot breathe on their own.

Since the spring, American medical device makers have radically ramped up the country’s ventilator capacity by producing more than 200,000 critical care ventilators, with 155,000 of them going to the Strategic National Stockpile. At the same time, doctors have figured out other ways to deliver oxygen to some patients struggling to breathe — including using inexpensive sleep apnea machines or simple nasal cannulas that force air into the lungs through plastic tubes.

But with new cases approaching 200,000 per day and a flood of patients straining hospitals across the country, public health experts warn that the ample supply of available ventilators may not be enough to save many critically ill patients.

“We’re now at a dangerous precipice,” said Dr. Lewis Kaplan, president of the Society of Critical Care Medicine. Ventilators, he said, are exceptionally complex machines that require expertise and constant monitoring for the weeks or even months that patients are tethered to them. The explosion of cases in rural parts of Idaho, Ohio, South Dakota and other states has prompted local hospitals that lack such experts on staff to send patients to cities and regional medical centers, but those intensive care beds are quickly filling up.

Public health experts have long warned about a shortage of critical care doctors, known as intensivists, a specialty that generally requires an additional two years of medical training. There are 37,400 intensivists in the United States, according to the American Hospital Association, but nearly half of the country’s acute care hospitals do not have any on staff, and many of those hospitals are in rural areas increasingly overwhelmed by the coronavirus.

“We can’t manufacture doctors and nurses in the same way we can manufacture ventilators,” said Dr. Eric Toner, an emergency room doctor and senior scholar at the Johns Hopkins Center for Health Security. “And you can’t teach someone overnight the right settings and buttons to push on a ventilator for patients who have a disease they’ve never seen before. The most realistic thing we can do in the short run is to reduce the impact on hospitals, and that means wearing masks and avoiding crowded spaces so we can flatten the curve of new infections.”

Medical association message boards in states like Iowa, Oklahoma and North Dakota are awash in desperate calls for intensivists and respiratory therapists willing to temporarily relocate and help out. When New York City and hospitals in the Northeast issued a similar call for help this past spring, specialists from the South and the Midwest rushed there. But because cases are now surging nationwide, hospital officials say that most of their pleas for help are going unanswered.

Dr. Thomas E. Dobbs, the top health official in Mississippi, said that more than half the state’s 1,048 ventilators were still available, but that he was more concerned with having enough staff members to take care of the sickest patients.

“If we want to make sure that someone who’s hospitalized in the I.C.U. with the coronavirus has the best chance to get well, they need to have highly trained personnel, and that cannot be flexed up rapidly,” he said in a news briefing on Tuesday.

Dr. Matthew Trump, a critical care specialist at UnityPoint Health in Des Moines, said that the health chain’s 21 hospitals had an adequate supply of ventilators for now, but that out-of-state staff reinforcements might be unlikely to materialize as colleagues fall ill and the hospital’s I.C.U. beds reach capacity.

“People here are exhausted and burned out from the past few months,” he said. “I’m really concerned.”

The domestic boom in ventilator production has been a rare bright spot in the country’s pandemic response, which has been marred by shortages of personal protective equipment, haphazard testing efforts and President Trump’s mixed messaging on the importance of masks, social distancing and other measures that can dent the spread of new infections.

Although the White House has sought to take credit for the increase in new ventilators, medical device executives say the accelerated production was largely a market-driven response turbocharged by the national sense of crisis. Mr. Trump invoked the wartime Defense Production Act in late March, but federal health officials have relied on government contracts rather than their authority under the act to compel companies to increase the production of ventilators.

Scott Whitaker, president of AdvaMed, a trade association that represents many of the country’s ventilator manufacturers, said the grave situation had prompted a “historic mobilization” by the industry. “We’re confident that our companies are well positioned to mobilize as needed to meet demand,” he said in an email.

Public health officials in Minnesota, Mississippi, Utah and other states with some of the highest per capita rates of infection and hospitalization have said they are comfortable with the number of ventilators currently in their hospitals and their stockpiles.

Mr. Whitaker said AdvaMed’s member companies were making roughly 700 ventilators a week before the pandemic; by the summer, weekly output had reached 10,000. The juggernaut was in part fueled by unconventional partnerships between ventilator companies and auto giants like Ford and General Motors.

Chris Brooks, chief strategy officer at Ventec Life Systems, which collaborated with G.M. to fill a $490 million contract for the Department of Health and Human Services, said the shared sense of urgency enabled both companies to overcome a thicket of supply-chain and logistical challenges to produce 30,000 ventilators over four months at an idled car parts plant in Indiana. Before the pandemic, Ventec’s average monthly output was 100 to 200 machines.

“When you’re focused with one team and one mission, you get things done in hours that would otherwise take months,” he said. “You just find a way to push through any and all obstacles.”

Despite an overall increase in the number of ventilators, some researchers say many of the new machines may be inadequate for the current crisis. Dr. Richard Branson, an expert on mechanical ventilation at the University of Cincinnati College of Medicine and an author of a recent study in the journal Chest, said that half of the new devices acquired by the Strategic National Stockpile were not sophisticated enough for Covid-19 patients in severe respiratory distress. He also expressed concern about the long-term viability of machines that require frequent maintenance.

“These devices were not built to be stockpiled,” he said.

The Department of Health and Human Services, which has acknowledged the limitations of its newly acquired ventilators, said the stockpile — nine times as large as it was in March — was well suited for most respiratory pandemics. “These stockpiled devices can be used as a short-term, stopgap buffer when the immediate commercial supply is not sufficient or available,” the agency said in a statement.

Projecting how many people will end up requiring mechanical breathing assistance is an inexact science, and many early assumptions about how the coronavirus affects respiratory function have evolved.

During the chaotic days of March and April, emergency room doctors were quick to intubate patients with dangerously low oxygen levels. They subsequently discovered other ways to improve outcomes, including placing patients on their stomachs, a protocol known as proning that helps improve lung function. The doctors also learned to embrace the use of pressurized oxygen delivered through the nose, or via BiPAP and CPAP machines, portable devices that force oxygen into a patient’s airways.

Many health care providers initially hesitated to use such interventions for fear the pressurized air would aerosolize the virus and endanger health care workers. The risks, it turned out, could be mitigated through the use of respirator masks and other personal protective gear, said Dr. Greg Martin, the chief of pulmonary and critical care at Grady Health Systems in Atlanta.

“The familiarity of taking care of so many Covid patients, combined with good data, has just made everything we do 100 times easier,” he said.

Some of the earliest data about the perils of intubating coronavirus patients turned out to be incomplete and misleading. Dr. Susan Wilcox, a critical care specialist at Massachusetts General Hospital, said many providers were spooked by data that suggested an 80 percent mortality rate among ventilated coronavirus patients, but the actual death rate turned out to be much lower. The mortality rate at her hospital, she said, was about 25 to 30 percent.

“Some people were saying that we should intubate almost immediately because we were worried patients would crash and have untoward consequences if we waited,” she said. “But we’ve learned to just go back to the principles of good critical care.”

Survival rates have increased significantly at many hospitals, a shift brought about by the introduction of therapeutics like dexamethasone, a powerful steroid that Mr. Trump took when he was hospitalized with the coronavirus. The changing demographics of the pandemic — a growing proportion of younger patients with fewer health risks — have also played a role in the improving survival rates.

Dr. Nikhil Jagan, a critical care pulmonologist at CHI Health, a hospital chain that serves Iowa, Kansas and Nebraska, said many of the coronavirus patients who were arriving at his emergency room now were less sick than the patients he treated in the spring.

“There’s a lot more awareness about the symptoms of Covid-19,” he said. “The first go-around, when people came in, they were very sick right off the bat and in respiratory distress or at the point of respiratory failure and had to be intubated.”

But the promising new treatments and enhanced knowledge can go only so far should the current surge in cases continue unabated. The country passed 250,000 deaths from the coronavirus last week, a reminder that many critically ill patients do not survive. The daily death toll has been rising steadily and is approaching 2,000.

“Ventilators are important in critical care but they don’t save people’s lives,” said Dr. Branson of the University of Cincinnati. “They just keep people alive while the people caring for them can figure out what’s wrong and fix the problem. And at the moment, we just don’t have enough of those people.”

For now, he said there was only one way out the crisis: “It’s not that hard,” he said. “Wear a mask.”

High numbers of Los Angeles patients complained about coughs as early as December, study says

The number of patients complaining of coughs and respiratory illnesses surged at a sprawling Los Angeles medical system from late December through February, raising questions about whether the novel coronavirus was spreading earlier than thought, according to a study of electronic medical records.

The authors of the report, published Thursday in the Journal of Medical Internet Research, suggested that coronavirus infections may have caused this rise weeks before U.S. officials began warning the public about an outbreak. But the researchers cautioned that the results cannot prove that the pathogen reached California so soon, and other disease trackers expressed skepticism that the findings signaled an early arrival.

The debate about the findings underscores just how much remains to be known about the coronavirus, which has killed at least 187,000 people in the United States, according to a Washington Post analysis.

“This is consistent with the growing body of data that suggests that there’s been community spread much earlier than we had anticipated,” said study author Joann G. Elmore, a doctor and epidemiologist at the David Geffen School of Medicine at the University of California at Los Angeles.

The researchers examined six years of electronic health records, representing nearly 10 million patients, at the UCLA health system from July 2014 through February. That included patient visits to three UCLA hospitals and to nearly 200 associated outpatient clinics.

Health agencies have surveillance systems in place to detect the early signals of disease outbreaks, such as a rise in patients with fever checking into hospitals. But medical records were an under-tapped resource, Elmore said. “People weren’t paying attention to the outpatient setting,” she said.

The study authors searched outpatient and emergency department reports that used the word “cough,” and tallied the number of people hospitalized for acute respiratory failure.

That approach revealed an uptick in patients that began the week of Dec. 22 and remained elevated for 10 weeks. The number of extra people exceeded the researchers’ predictions by 50 percent, totaling about 1,000 more patients compared with the previous five flu seasons.

Influenza cannot be ruled out as a cause of the increase, Elmore said. “And, you know, we did see a bad bout of flu this year,” she said. But what gave her pause was the consistent, weeks-long trend found only in this most recent season and not others.

Some experts said they doubted that coronavirus infections were the likely cause of respiratory problems in California so far back in time. “The data countywide would suggest that it really began to spread in March,” said Brad Spellberg, chief medical officer at the Los Angeles County+USC Medical Center, who was not involved with the new research.

Although the virus may have infected a small number of people sooner than previously reported, Spellberg said he doubted that “meaningful transmission” occurred in December or January.

Using data from emergency departments that reported patients with flu-like illnesses, Spellberg and his colleagues observed two peaks in patients in December and February, as they reported in JAMA this spring.

Those increases were consistent with a severe flu season, Spellberg said. Los Angeles’s third spike in flu-like illnesses, this time caused by the coronavirus, came later.

What’s more, between March 2 and March 18, only 5 percent of 131 patients with flu-like illnesses tested positive for the coronavirus in the JAMA study. Spellberg said that if the virus had an earlier foothold in California, he would have expected that percentage to be higher. “You would have seen an explosion of cases,” he said.

Understanding how long the virus circulated within a population helps refine epidemiological models of transmission. Infectious-disease scientists and doctors in many pockets of the world are eager to uncover when the coronavirus first spread outside of China.

In late December 2019, Chinese health officials identified clusters of viral pneumonia in Wuhan. Researchers sequenced the culprit’s genome, describing the new coronavirus strain, in early January. The first officially reported U.S. case of coronavirus, a man who traveled home from Wuhan, occurred two weeks later.

A few observations indicate that the virus may have traveled farther, earlier, before it flared into a global pandemic. A study of Italian sewage revealed traces of the virus in December. When researchers retested a nasal swab from a man hospitalized near Paris dating to Dec. 27, they detected the coronavirus.

Genetic sequencing of coronavirus samples in New York suggests that the virus was spreading there by the end of January. In April, two autopsies in Santa Clara County, Calif., pushed back the first U.S. covid-19 deaths from late to early February.

Study author Judith Currier, a UCLA infectious-disease physician, said that when it comes to people who wonder whether they were exposed to the virus many months ago, she does not recommend “antibody testing for people who never had a symptomatic illness,” citing guidelines from the Centers for Disease Control and Prevention.

“If someone had a compatible clinical illness but never had testing for covid during that time, antibody testing could help to confirm,” she said. “Although we don’t know how long the antibodies last, so it would not be definitive.”





Six months ago, Trump said that coronavirus cases would soon go to zero. They … didn’t.


But with new constraints on testing, Trump may get his wish eventually.

It was exactly six months ago Wednesday when the spread of the coronavirus in the United States had become too significant for President Trump to wave away. He and several members of the team planning the administration’s response held a news briefing designed to inform the public about the virus and, more important, to allay concerns.

This was the briefing in which Trump made one of his most wildly incorrect assertions about what the country could expect.

“The level that we’ve had in our country is very low,” Trump said, referring to new confirmed infections, “and those people are getting better, or we think that in almost all cases they’re better, or getting. We have a total of 15. We took in some from Japan — you heard about that — because they’re American citizens, and they’re in quarantine.”

That part was generally true. At the time, there had been only a smattering of confirmed cases, with the addition of passengers from the cruise ship Diamond Princess pushing the confirmed total to more than 50.

“So, again,” he added later, “when you have 15 people, and the 15 within a couple of days is going to be down to close to zero, that’s a pretty good job we’ve done.”

It was a brash prediction and seemingly an off-the-cuff one. Trump’s point was less about what was going to happen than arguing that his administration had done a good job. But by linking those two things, he made it simple for observers to use his assertion that the number of cases would fade as a baseline for measuring everything that followed.

Over time, more cases from the period before Feb. 26 would be discovered, including two early deaths in California from covid-19, the disease caused by the virus. There were actually almost 200 cases that would eventually be confirmed by the time Trump was saying the country would go from 15 to zero.

The experts standing behind Trump would have known that Trump’s claims were inaccurate. As the briefing was underway, The Washington Post reported a confirmed case of “community spread” — a documented infection that couldn’t be traced to international travel. In other words, it was uncontained: The virus was moving from person to person without impediment or detection.

Although about 200 cases in that period eventually would be confirmed, even that number was far lower than the reality. Researchers can use documented cases to estimate the number of cases that weren’t being detected and that also weren’t later confirmed through testing. For example, an estimate produced by data scientist Youyang Gu puts the likely number of new infections on Feb. 26 somewhere in the range of 13,000 to 25,000.

On that day alone.

Within a month, the country would go from Trump’s 15 cases to nearly 88,000 cases. By April 26, the total was nearly a million. By May 26, 1.7 million. The most recent total is north of 5.7 million.

That steady increase is in part a function of Trump repeating the same mistake over and over, portraying the pandemic as ending or functionally ended. As cases faded a bit in May and June, he pushed for a return to normal economic activity, triggering a new surge in confirmed cases. That second increase has been fading for about a month, happily, but the country is still adding 33 percent more confirmed new cases each day than it did at the peak in April.

That’s confirmed cases, a metric that relies on testing. Gu’s estimates of the actual spread of the virus put the country about 40 percent below the peak in daily new cases, which was reached in early July.

Trump, of course, blames testing for revealing the scale of the pandemic in the first place. He has a point, in a way: Had the United States never managed to solve its problems with testing, something that took weeks, there wouldn’t have been millions of confirmed cases. There would still have been millions of cases or, perhaps, tens of millions of cases. We just wouldn’t have known how many there were.

It has been about two months since Trump held a political rally in Tulsa, contributing to a new surge of cases in the city. There, he made a tongue-in-cheek reference to asking his team to slow down on testing, because it was pushing the number of confirmed cases higher. As they say, though, each joke contains a grain of truth, and it was clear that Trump, in fact, would be happy to see the number of tests drop so that the number of confirmed cases did as well.

Data compiled by the COVID Tracking Project show that he has gotten his wish, to a degree. Over the past month, the number of tests being completed each day in the United States has dropped by nearly one-fifth.

Part of this is a function of interference from natural disasters, with storms in Florida and fires in California limiting testing capacity. Part of it, too, is probably a function of the drop in the number of cases coming back positive. Fewer new cases means fewer people feeling sick and seeking tests to confirm an infection. The drop in the percent of tests coming back positive reinforces that trend.

But, increasingly, part of it will stem from the administration de-emphasizing testing. New guidance published by the Centers for Disease Control and Prevention suggested that those who had been in contact with an infected person no longer needed to be tested, particularly when asymptomatic.

This, too, has been something Trump has talked about a lot, complaining that people without symptoms were being tested and confirmed as positive — and added to the total number of infections.

“Many of those cases are young people that would heal in a day,” Trump said in an interview on July 19. “They have the sniffles and we put it down as a test.”

The reason it’s important to track asymptomatic cases, of course, is that those people can still infect others. To defeat the pandemic, we need to contain it, and the new CDC approach runs the significant risk of leaving large holes in that containment effort. But, with the presidential election only about 70 days away, it will mean fewer confirmed cases.

The irony of Trump’s complaints about the virus from the outset is that the United States’ confirmed infection totals already have been minimized because of limited testing. The reason Trump was able to claim that there were only 15 cases six months ago was that the administration had spent the month since the first confirmed case in the country unable to put together a robust testing regimen that would allow the virus to be constrained. South Korea, where such a regimen was quickly implemented, actually did see its virus numbers drop to near zero.

In other words, Trump’s prediction was not only wrong, it was wrong in large part because Trump’s team hadn’t done what would have been needed to make it come true. Trump portrays himself as an unwitting victim of the pandemic, but his comment six months ago Wednesday is a good reminder that he can put a lot of the blame for his position on himself.




The two sides of America’s coronavirus response

The two sides of America's coronavirus response - Axios

America’s bungled political and social response to the coronavirus exists side-by-side with a record-breaking push to create a vaccine with U.S. companies and scientists at the center.

Why it matters: America’s two-sided response serves as an X-ray of the country itself — still capable of world-beating feats at the high end, but increasingly struggling with what should be the simple business of governing itself.

What’s happening: An index published last week by FP Analytics, an independent research division of Foreign Policy, ranked the U.S. 31st out of 36 countries in its assessment of government responses to COVID-19.

  • That puts it below developed countries like New Zealand and Denmark, and also lower than nations with fewer resources like Ghana, Kenya and South Africa.
  • The index cited America’s limited emergency health care spending, insufficient testing and hospital beds and limited debt relief.

By the numbers: As my Axios colleague Jonathan Swan pointed out in an interview with President Trump, the U.S. has one of the worst per-capita death rates from COVID-19, at 50.29 per 100,000 population.

Yes, but: Work on a COVID-19 vaccine is progressing astonishingly fast, with the Cambridge-based biotech company Moderna and the National Institutes of Health announcing at the end of July that they had begun Phase 3 of the clinical trial.

  • Their efforts are part of a global rush to a vaccine, and while companies in the U.K. and China are jockeying for the lead, U.S. companies and the NIH’s resources and expertise have been key to the effort.
  • Anthony Fauci has said he expects “tens of millions” of doses to be available by early 2021, a little over a year after the novel coronavirus was discovered.
  • If that turns out to be the case, “the Covid-19 vaccine could take a place alongside the Apollo missions as one of history’s greatest scientific achievements,” epidemiologist Michael Kinch recently wrote in STAT.

So which is the real American response to COVID-19? The bungled testing policies, the politically driven rush to reopen, the tragic racial divide seen in the sick and the dead? Or the warp-speed work to develop a vaccine in a year when most past efforts took decades?

Be smart: It’s both.

The bottom line: It can often feel as if there are two Americas, and not even a virus that has spread around the world seems capable of bridging that gap.





Fauci has been an example of conscience and courage.–I1P3ioLPA7ka7Ew0XT_EA&utm_campaign=wp_main&utm_medium=social&utm_source=facebook

Opinion | Fauci has been an example of conscience and courage ...

When historians try to identify the most shameful documents from the Trump administration, a few are likely to stand out. For unconstitutional bigotry, it is hard to beat the initial executive order banning travel to the United States from Muslim countries. For cruelty and smallness, there is the “zero tolerance” directive to federal prosecutors that led to family separations at the border. For naked corruption, there is the transcript of the quid-pro-quo conversation between President Trump and the president of Ukraine.

But for rash, foolish irresponsibility, I’d nominate the opposition research paper recently circulated by the White House in an attempt to discredit the National Institute of Allergy and Infectious Diseases’ Anthony S. Fauci. As reported by The Post, the document recounted a number of instances — on community transmission, asymptomatic transmission and mask wearing in particular — where Fauci’s views have shifted over time. As far as I know, this official record is unique: A White House attack on the government’s leading infectious-disease specialist during a raging pandemic. It indicates an administration so far gone in rage, bitterness and paranoia that it can no longer be trusted to preserve American lives.

From a purely political standpoint, it is understandable that the administration would want to divert attention from its covid-19 record. Trump’s policy of reopening at any cost is exacting a mounting cost. Five months into the greatest health crisis of modern U.S. history, there are still serious problems with supply chains for protective equipment. There are still long wait times for testing results in many places. The contact tracing process in many communities remains (as one health expert described it to me) “a joke.” More than 132,000 Americans have died.

Rather than addressing these failures, Trump has chosen to sabotage a public official who admits their existence. Rather than confronting these problems, Trump wants to ensure his whole administration lies about them in unison. The president has surveyed America’s massive spike in new infections and thinks the most urgent matter is . . . message discipline.

It is true that a number of Fauci’s views on the novel coronavirus have evolved (though some of the administration’s charges against him are distorted). But attacking a scientist for making such shifts is to willfully misunderstand the role of science in the fight against disease. We do not trust public health officials during an emerging pandemic because they have fully formed scientific views from the beginning. We trust them because 1) they are making judgments based on the best available information and 2) they have no other motive than the health of the public. If, say, health officials were initially mistaken about the possibility of asymptomatic transmission, it is not failure when they change their views according to better data. It is the nature of the scientific method and the definition of their duty.

In the inch-deep world of politics, amending your view based on new information is a flip-flop. In epidemiology, it is known as, well, epidemiology.

Meanwhile, the president is failing according to both requirements of public trust. Trump is not making judgments based on the best available information. And he clearly has political goals that compete with (and often override) his commitment to public health. The president is hoping against hope that the public will forget about the virus until November, or at least about the federal role in fighting it. To apply a veneer of normalcy, he is holding public events that endanger his staff and his audience and is planning a Republican convention that will double as a petri dish.

It now seems likely that the most decisive moment of the American pandemic took place in mid-April when new cases began to stabilize around 25,000 a day. Even four or six more weeks of firm presidential leadership — urging the tough, sacrificial application of stay-at-home orders — might have reduced the burden of disease to more sustainable levels, as happened in Western Europe. And this would have relieved stress on systems of testing, tracing and treatment.

But Trump’s nerve failed him. Instead of holding firm, he began siding with populist demands for immediate opening, pressuring governors to take precipitous steps and encouraging skepticism about basic public health information and measures. This may well have been the defining moment of the Trump presidency. And he was weak, weak, weak.

It is typical for Trump to shift blame. But in this case, the president has selected his fall guy poorly. Fauci has been an example of conscience and courage in an administration that values neither. When Trump encourages a contrast to his own selfishness and cravenness, he only damages himself.





Why our “starved” public health system was unprepared for COVID-19

Exclusive: Health spending in Brazil states as small as USD 20 ...

The American public health system has long been considered one of the best in the world, but decades of underfunding have left states and counties woefully ill-equipped to handle the worst pandemic in a century.

An extensive analysis by Kaiser Health News and the Associated Press found that over the past ten years, per-capita spending by state and local public health departments has dropped by 16 and 18 percent, respectively, leaving our public health system “underfunded and under threat, unable to protect the nation’s health”.

Public health departments are mandated to provide a laundry list of critical functions, from restaurant inspections and water testing to immunizations. But over time, many of these functions have been privatized, and staff and budgets reduced. Both were cut further as state budgets tightened.

The federal government has extended $13B in emergency funding, but many local public health departments have still been forced to furlough workers during the pandemic. Citing comparisons to the funding extended during other crises like Zika and the H1N1 influenza, experts are concerned that baseline budgets will continue to decline.

Moreover, public health workers face unprecedented cultural challenges, and are often disrespected by political and clinical leaders. And as public health workers are putting themselves at risk of COVID exposure just to do their jobs, many face resentment and anger from angry citizens who blame them for the policies they are charged to enforce—with some local public health leaders even resigning due to threats and intimidation.

The current crisis has shown that we need a more expansive, and better coordinated public health infrastructure. Getting there will require not just more investment, but repairs to the foundation of this critical national asset.




HCA nurses issue 10-day strike notice at California hospital

UPDATE: June 23, 2020: Riverside Community Hospital on Tuesday told Healthcare Dive the motivation behind the union’s strike notice “has very little to do with the best interest of their members and everything to do with contract negotiations.” The system said it has plans to ensure appropriate staffing and continued services for any type of event, including a strike.

Dive Brief:

  • Nurses at HCA Healthcare’s Riverside Community Hospital in south-central California issued a 10-day strike notice last week, citing a breakdown in discussions over safety and staffing, the union representing them said Monday.
  • The nurses plan to strike from Friday, June 26 through July 6, prior to starting contract negotiations with HCA on July 7.  The union plans to push for better staffing and safety measures, particularly hospital preparedness during states of emergency.
  • Neither HCA nor Riverside were available for comment, but the hospital told Becker’s Hospital Review it had hoped the union “would not resort to these tactics” during the COVID-19 pandemic and said it had not laid off or furloughed any employees due to the crisis.

Dive Insight:

The strike notice follows a recent job posting from the nation’s biggest for-profit chain seeking qualified nurses in the Los Angeles area in the event of a job action or work stoppage.

Nurses at Riverside Community Hospital pushed for an improved staffing agreement last year and got it — but the hospital recently ended that agreement, resulting in fewer RNs taking care of more patients amid a pandemic, according to the union.

Insufficient personal protective equipment, inadequate safety measures and recycling of single-use PPE is also putting nurses at increased risk of COVID-19 infection, the union alleges.

Scores of RNs at the hospital have fallen ill with COVID-19, according to a release, including deaths of an environmental services worker and a lab technician, that “have not caused RCH to improve staffing or increase PPE.”

PPE shortages have been a problem at all of the 27 hospitals SEIU Local 121 RN represents, the union says. But a member survey found HCA hospitals were particularly unprepared for shortages. Only 27% of local 121 RN members at HCA hospitals reported having access to N95 respirators in their unit, significantly lower than other hospitals surveyed, according to the union.

Nashville-based HCA has received the most among for-profits in Coronavirus Aid, Relief, and Economic Security Act funding so far, about $1 billion. The amount is about 2% of HCA’s total 2019 revenue.

The 184-hospital system said it has not had to furlough employees like other systems have, though some employees have been redeployed or seen their hours and pay decrease. HCA implemented a program providing seven weeks paid time off at 70% of base pay that was scheduled to expire May 16, but has been extended through this week.

A spokesperson with the country’s largest nurses union, National Nurses United, told Healthcare Dive the program isn’t technically a furlough because some HCA nurses participating said they must remain on call or work rotating shifts.

NNU has also recently fought with HCA over other pandemic-related labor issues. Nurses at 15 HCA hospitals protested in late May over contractually bargained wage increases the hospital says it can’t deliver due to financial strains, asking nurses to give up the increases or face layoffs.

Another dispute involves a last-minute change mandating in-person voting for nurses deciding whether to form a union at HCA’s Mission Hospital in Asheville, North Carolina, according to an NNU release.

SEIU Local 121 RN said HCA can “easily weather this storm financially, continue to provide profits for their shareholders, while at the same time support and protect nurses as they fight this disease and fight to save their community.”





Shutdowns prevented 60 million coronavirus infections in the U.S., study finds

Shutdowns prevented 60 million coronavirus infections in the U.S. ...

Shutdown orders prevented about 60 million novel coronavirus infections in the United States and 285 million in China, according to a research study published Monday that examined how stay-at-home orders and other restrictions limited the spread of the contagion.

A separate study from epidemiologists at Imperial College London estimated the shutdowns saved about 3.1 million lives in 11 European countries, including 500,000 in the United Kingdom, and dropped infection rates by an average of 82 percent, sufficient to drive the contagion well below epidemic levels.

The two reports, published simultaneously Monday in the journal Nature, used completely different methods to reach similar conclusions. They suggest that the aggressive and unprecedented shutdowns, which caused massive economic disruptions and job losses, were effective at halting the exponential spread of the novel coronavirus.

“Without these policies employed, we would have lived through a very different April and May,” said Solomon Hsiang, director of the Global Policy Laboratory at the University of California at Berkeley, and the leader of the research team that surveyed how six countries — China, the United States, France, Italy, Iran and South Korea — responded to the pandemic.

He called the global response to covid-19, the disease caused by the virus, “an extraordinary moment in human history when the world had to come together,” and said the shutdowns and other mitigation measures resulted in “saving more lives in a shorter period of time than ever before.”

The two reports on the effectiveness of the shutdowns come with a clear warning that the pandemic, even if in retreat in some of the places hardest hit, is far from over. The overwhelming majority of people remain susceptible to the virus. Only about 3 percent to 4 percent of people in the countries being studied have been infected to date, said Samir Bhatt, senior author of the Imperial College London study.

“This is just the beginning of the epidemic: we’re very far from herd immunity,” Bhatt said Monday in an email. “The risk of a second wave happening if all interventions and precautions are abandoned is very real.”

In a teleconference with reporters later, Bhatt said economic activity could return to some degree so long as some interventions to limit viral spread remain in place: “We’re not saying the country needs to stay locked down forever.”

The Berkeley study used an “econometric” model to estimate how 1,717 interventions, such as stay-at-home orders, business closings and travel bans, altered the spread of the virus. The researchers looked at infection rates before and after the interventions were imposed. Some of these interventions were local, and some regional or national. The researchers concluded that the six countries collectively managed to avert 62 million test-confirmed infections.

Because most people who are infected never get tested, the actual number of infections that were averted is much higher — about 530 million in the six countries, the Berkeley researchers estimated.

Timing is crucial, the Berkeley study found. Small delays in implementing shutdowns can lead to “dramatically different health outcomes.” The report, while reviewing what worked and what made little difference, is clearly aimed at the many countries still early in their battle against the coronavirus.

“Societies around the world are weighing whether the health benefits of anti-contagion policies are worth their social and economic costs,” the Berkeley team wrote. The economic costs of shutdowns are highly visible — closed stores, huge job losses, empty streets, food lines. The health benefits of the shutdowns, however, are invisible, because they involve “infections that never occurred and deaths that did not happen,” Hsiang said.

That spurred the researchers to come up with their estimates of infections prevented. The Berkeley team did not produce an estimate of lives saved.

One striking finding: School closures did not show a significant effect, although the authors cautioned that their research on this was not conclusive and the effectiveness of school closures requires further study. Banning large gatherings had more of an effect in Iran and Italy than in the other countries.

In discussing their findings Monday with reporters in the teleconference, leaders of the two research teams said challenges exist in crafting their models and thus there are uncertainties in the final estimates.

Bhatt, for example, said the model used by his team is highly sensitive to assumptions about the infection fatality rate, estimates for which have varied among researchers and from one country to another. He said his team was heartened to see that its estimates for the number of people infected so far is generally consistent with antibody surveys that attempt to calculate the attack rate of the virus.

Ian Bolliger, one of the Berkeley researchers, acknowledged the difficulty in obtaining reliable numbers for coronavirus infections given the haphazard pattern of testing for the virus. Both research teams said the peer review process had made their findings more robust.





COVID-19 impact on hospitals worse than previously estimated

Coronavirus | MSF

Factors such as how many patients would need ICU treatment, average length of stay and fatality risk are straining hospital resources.

When it became evident that the COVID-19 pandemic would spread across the U.S., lawmakers, scientists and healthcare leaders sought to predict what the financial and operational impact on hospitals would be. In those early days, policymakers relied on data from China, where the pandemic originated.

Now, with the benefit of time, the early predictions seriously underestimated the coronavirus’ impacts. University of California Berkeley and Kaiser Permanente researchers have determined that certain factors — such as how many patients would need treatment in intensive care units, average length of stay and fatality risk — are much worse than previously anticipated, and put a much greater strain on hospital resources.


Looking primarily at California and Washington, data showed the incidents of COVID-19-related hospital ICU admissions totaled between 15.6 and 23.3 patients per 100,000 in northern and southern California, respectively, and 14.7 per 100,000 in Washington. This incidence increased with age, hitting 74 per 100,000 people in northern California, 90.4 per 100,000 in southern California, and 46.7 per 100,000 in Washington for those ages 80 and older. These numbers peaked in late March and early April.

Those numbers are greater than the initial forecast, especially when factoring in the virus itself. Modeling estimates based on Chinese data suggested that about 30% of coronavirus patients would require ICU care, but in the U.S., the probability of ICU admissions was 40.7%. Male patients are more likely to be admitted to the ICU than females, and also are more likely to die.

Length of stay was also higher than had been predicted. By April 9, the median length of stay was 9.3 days for survivors and 12.7 days for non-survivors. Among patients receiving intensive care, the median stay was 10.5 days, although some patients stayed in the ICU for roughly a month.

Long durations of hospital stay, in particular among non-survivors, indicates the potential for substantial healthcare burden associated with the management of patients with severe COVID-19 — including the need for ventilators, personal protective equipment including N95 masks, more ICU beds and the cancellation of elective surgeries.

The considerable length of stay among COVID patients suggests that unmitigated transmission of the virus could threaten hospital capacity as it has in hotspots such as New York and Italy. Social distancing measures have acted as a stop-gap in reducing transmission and protecting health systems, but the authors said hospitals would do well to ensure capacity in the coming months in a manner that’s responsive to changes in social distancing measures.


These challenges have placed a financial burden on hospitals that can’t be overstated. In fact, a Kaufman Hall report looking at April hospital financial performance showed that steep volume and revenue declines drove margin performance so low that it broke records.

Despite $50 billion in funding allocated through the CARES Act, operating EBITDA margins fell to -19%. They fell 174%, or 2,791 basis points, compared to the same period last year, and 118% compared to March. This shows a steady and dramatic decline, as EBITDA margins were as high as 6.5% in April.



How tariffs ravaged the COVID-19 medical supply chain

Trump's Tariffs Leave the U.S. Short on Vital Medical Supplies - WSJ

Months into the pandemic, the U.S. faces an ongoing shortage of PPE and some of it is still subject to tariffs.

Gojo Industries, which makes Purell, builds automated hand sanitizer dispensers in the U.S. The devices rely on an electronic input made in China. But in early March, the U.S. Trade Representative (USTR) turned down Gojo’s tariff exemption request for the specific part needed for its dispensers, just before President Donald Trump declared a national emergency due to COVID-19.

The government later reversed its decision and waived the tariff after a senator from Ohio, where Gojo Industries is based, pressured the USTR because of the product’s importance to public health.

But several months into the COVID-19 pandemic, many consumers still struggle to find public-health-related products, from hand sanitizer to wipes. There’s also a shortage of personal protective equiptment (PPE) in the United States, and some of it is still subject to tariffs, throwing a wrench into pandemic preparedness and response.

Health supply chain experts sound the warning bell

The healthcare industry warned the Trump administration long before COVID-19 that imposing tariffs on Chinese-produced essential healthcare products put the nation’s public health preparedness at risk.

In August 2018, Matt Rowan, president of the Health Industry Distributors Association (HIDA) told the U.S. Trade Representative (USTR) 301 Committee that products on the proposed list were widely used in healthcare settings and “are a critical component of our nation’s response to public health emergencies, such as Ebola.”

Tariffs on items like masks, medical gloves, isolation gowns and wet wipes would not only increase U.S. healthcare costs, but impact government and commercial suppliers supporting patients and providers during a medical crisis, the industry warned.


“We did not make up for the lack of imports from China by more imports from the rest of the world.”

Jennifer Hillman

Senior fellow for trade and international political economy, Council on Foreign Relations


Disrupting this supply chain would erode the industry’s ability to deliver quality outcomes, and “placing tariffs on these products would lead to product shortages and further exacerbate public health challenges during times of crisis. It would significantly limit the ability of all levels of government, as well as the commercial healthcare supply chain, to adequately support response efforts during emergency events,” Rowan said.

In spite of healthcare industry testimony, the U.S. slapped 15% to 25% tariffs on many of these essential healthcare items. That included 25% Section 301 tariffs on items like disposable medical headwear, hand sanitizers and pulse oximeters. It included 15% Section 301 tariffs on medical protective clothing, protective goggles, and Nitrile and sterile gloves.

In 2018, the American Action Forum estimated if import numbers remained consistent, medical supply costs would rise by $400 million.

“A good portion of the reason why we are in such a difficult position is imports of those products went way down once those tariffs were imposed on China,” Jennifer Hillman, senior fellow for trade and international political economy at the Council on Foreign Relations, told reporters on a press call. “Our traditional stockpiles, the amount that we had just in storage, by FEMA, by Veterans Affairs, by HHS, and by a lot of state and local hospitals, they decreased the amount of their imports and decreased their stockpiles because of the tariffs.”

Shefali Kapadia / Supply Chain Dive, data from World Trade Organization

In placing the tariffs, one Trump administration goal was for buyers to procure items from other countries or manufacture in the U.S. instead. And that happened, but not to the extent necessary to maintain the stockpiles.

“We did not make up for the lack of imports from China by more imports from the rest of the world,” Hillman said. China was the largest exporter of medical face masks globally, accounting for 25% of the world’s supply in 2019, according to the World Trade Organization (WTO).

The U.S. was the largest medical products importer during the last three years, with 19% of total world imports of these products in 2019, according to the WTO. Personal protective products (including face masks, hand sanitizer and protective eyewear) made up 10% of U.S. medical imports. Worldwide trade of products labeled “critical” and in severe shortage during the pandemic, included 1.7% of the total world trade for 2019, totaling $597 billion. The U.S. imported $5.2 billion in medical equipment in 2019.

The time-consuming exemption process

Trump refused a blanket exemption for medical products when COVID-19 hit, but did grant some exemptions retroactively to Sept. 1, 2019, through Sept. 1, 2020, on supplies like sterile drapes, disposable gowns, some face masks and disposable shoe covers. The government granted exemptions in executive orders on March 10, March 16 and March 17.

“They issued over 200 exclusions from the tariffs, with more than a hundred of these items are the ones that were needed for medical devices and to fight COVID,” said Hillman.

Still, $1.1 billion worth of healthcare imports that could be used for treating COVID-19 remain subject to the 25% tariffs, according to a report by Chad P. Brown, senior fellow at the Peterson Institute for International Economics. Tariffs from another $3.3 billion of critical healthcare product imports were lowered from 15% to 7.5%.

General Motors (GM), partnering with Ventec to produce ventilators under the Defense Production Act, needed to source more than 700 components for the new machines. While GM could obtain most from North America, it sourced components from a handful of categories from China, which fell under a 25% tariff. They included grommets, filter parts, compressor silencers and a power cord set. GM requested exclusions from the USTR for individual parts.

GM is producing ventilators in response to the pandemic. The company needed to source more than 700 component parts for the ventilators, many of which come from China and face 25% tariffs.
AJ Mast for General Motors

These types of requests are time-consuming, especially when efforts might be better spent on other priorities during this crisis, according to legislators. Senators on both sides of the aisle pointed this out in an April letter to U.S. Trade Representative Robert Lighthizer, saying “[companies] should not be subjected to the lengthy process of submitting tariff exemption requests for each individual input required to make products essential for addressing the ongoing pandemic.”

Tethered to China

Procuring from outside of China can alleviate the risk of single sourcing and increased costs from tariffs, but it’s not always possible due to availability of raw materials, FDA clearance or production capabilities,

In June 2019, Lara Simmons, Group President of Medline Industries, explained to the USTR why a manufacturer wasn’t easily able to source many of its healthcare products, like gloves, outside of China. She said 97% of vinyl gloves come from China.

“These products are not made in the United States and some of these products are effectively available only from China. Starting production in the U.S. or any third country would be a time-consuming expensive process due to the FDA regulatory procedure that is required for these products,” she said.

The process for FDA regulated Class I and Class II medical devices can take more than two years, she said, and includes development and installation of environmental controls, facility upgrades, equipment purchase, installation, process validation and multiple rounds of audits to ensure regulatory compliance and verification of the quality system effectiveness.

Personal protective products include face masks, hand soap, sanitizer and protective spectacles.
Shefali Kapadia / Supply Chain Dive, data from World Trade Organization

Even gloves used for hospital cleaning and industrial food prep are in short supply, sending buyers back to China in spite of high tariffs.

Minnesota-based Global Glove & Safety Manufacturing applied for a tariff exemption for unsupported gloves (rubber gloves without a fabric lining), which are subject to a 25% tariff. The company’s clients that traditionally use disposable supported gloves can’t keep those in stock and are now using unsupported gloves.


“Once stability is achieved in the marketplace, we won’t buy from China for unsupported gloves, especially because of the tariffs.”

Tanner Brehmer

Product development manager, Global Glove & Safety Manufacturing

Global Glove typically buys from producers in countries including Malaysia, Sri Lanka and Thailand, but due to lockdowns and limited production in those countries, it’s trying to source some from China. “It’s tough because nothing is really shipping and lead times are pushed out so far. We don’t know when we’ll get it from other countries,” Tanner Brehmer, the company’s product development manager, told Supply Chain Dive.

The 25% tariff on the gloves produced in China greatly increases the cost, yet China is one of the only countries producing these products at full speed, he said. So in spite of tariffs, his company may move some procurement back to China. “Once stability is achieved in the marketplace, we won’t buy from China for unsupported gloves, especially because of the tariffs,” Brehmer said.

A diversified future?

Lighthizer and the Trump administration has a long-term vision for the tariffs. “Indeed, if there is one lesson to be drawn from this crisis, it is that dependence on other countries as the source of key medical products has created a strategic vulnerability for the U.S. By encouraging diversification of supply chains and—better yet—more manufacturing in the U.S., President Trump’s economic and trade policies are helping to overcome that vulnerability,” Lighthizer wrote in the The Wall Street Journal.

As healthcare systems sourced PPE and other supplies to treat COVID-19, they often paid the tariffs if needed, even if that meant paying more for the products. Healthcare systems and the government also purchased from manufacturing companies converting their domestic factories to produce needed items for COVID-19 treatment.


“We need a more resilient supply chain, which means we need to have multiple sources of supply.”

Jennifer Hillman

Senior fellow for trade and international political economy, Council on Foreign Relations


Which of these production lines will continue when the acute need for PPE is over, is hard to know. However, healthcare systems are now more aware of the risk in relying on foreign sources for their supplies.

“We need a more resilient supply chain, which means we need to have multiple sources of supply rather than sole sources of supply, and we need to do a better job of creating stockpiles,” said Hillman. “Part of the reason why we’re in such a world of hurt is because of our stockpiles were allowed to be depleted, again, in response to these tariffs.”