Personal Protective Equipment, or PPE, in a healthcare context is simply equipment that is worn by healthcare workers to protect against exposure to potentially contagious viruses and other diseases that their patients may be carrying. Some examples of PPE include face masks, gloves, eye protection, full body suits, and respirators as listed in Table 1.

Table 1. PPE items with sample price range as of May 2020. Prices can vary by date and supplier.

In this paper, we will use the term PPE to refer to such equipment, but it’s important to remember that it implies a number of items that serve different purposes and may experience varying degrees of utilization and therefore, have different consumption rates. Gloves worn on the hands, obviously, can experience more wear & tear and may need to be replaced more frequently than gowns or a face shield. Face shields are also easier to clean and therefore safer to reuse than other PPE items. Many PPE items are meant to be disposed of after each use, however reuse of these items tends to increase in times of critical shortage.

The manufacture and distribution of PPE equipment has been complicated by the COVID-19 pandemic. For one, the shutdown enacted across many states and countries to slow the spread of COVID-19 slowed all manufacturing, including production of PPE. Between the closing of various businesses that support production of PPE and introducing new, unfamiliar social distancing guidelines in the workplace, it is easy to see how PPE production levels has been affected by such changes.

Geopolitical issues are another contributor to the reduced availability of PPE. The pandemic has stressed political lines within the United States (U.S.) and beyond. For instance, in the U.S., some state leaders accuse the president of intercepting packages of PPE supplies, leaving many to search and acquire PPE from other countries and unspecified agencies.[4] In addition, many nations, including China and India, have cut exports of key medical equipment. Lastly, hoarding – a natural response when the accessibility of critical items is unknown – is yet another major concern surrounding PPE. When critical items are believed to be in short supply relative to need and when there is a lack of clarity on how much quantity is truly needed, many panic and rush to buy all available supplies – even if the purchasing becomes excessive. This alters the availability of PPE on the market leaving some with excess equipment while others have an insufficient quantity or none. The use of data analytics can be helpful in determining the projected demand for PPE and the labor force that will use – as well as can produce – the necessary levels of PPE.

HSR.health PPE Needs Assessment

Data analytics provides insight into how much and when PPE will be needed. HSR.health identifies these insights based on its previous work supporting emergency response efforts, by adapting its Health Risk Index, developed with support from the U.S. Federal Emergency Management Agency (FEMA) and the U.S. Geological Survey (USGS), to address the COVID-19 Pandemic. To aid the Pandemic, HSR.health initially developed a Transmission Risk Index to predict the locations of future outbreaks, as well as a Mortality Risk Index to identify the regions with the highest risk of critical illness and death due to the virus – each at the County, ZIP Code, and Census tract levels. One of the issues that arose in the response to COVID-19 was the availability of PPE. In researching the pandemic for the purpose of addressing this issue, it became clear that there are three phases with respect to determining PPE needs: The Pre-pandemic or Planning Phase is the time period between when a potential pandemic-causing contagious disease is discovered in the world, but before it hits locally. For COVID-19, this was January and February 2020 for much of the United States. This is followed by the Pandemic Response Phase when active measures to combat and control the spread of the pandemic are underway. Lastly, there is a Pandemic Recovery Phase – in our current pandemic, this is the time period where state and national economies are beginning to reopen, but social distancing and other guidelines to slow the spread remain in place.

After establishing the three phases of a pandemic, HSR.health identified an algorithm that leverages data on the workforce that would need PPE, the COVID-19 case counts, as well as its transmission risk and mortality risk indices, that when taken together provides a range for daily PPE supply that can be applied to an individual health system, or more broadly to entire economies at the National, State, City or County levels.

In the Pre-Pandemic stage, the risk-based estimate predicts a range of daily PPE needs to adequately supply healthcare and essential workers when facing the pandemic. This phase allows time to plan for the actual response. In the Pandemic Response Phase, buyers can continue to acquire PPE within the risk-based range and may also begin to develop insight into their own consumption rate as they respond to the pandemic. This consumption rate can be integrated into the algorithm to further refine the prediction of PPE needs and guide purchasing levels. In the Pandemic Recovery Stage, the workforce can be expanded to include all industries where social distancing is not practical, such as hair and nail salon staff, teachers, cashiers, drivers, restaurant staff, or anyone whose job involves close proximity to others. The differences in these phases are highlighted in Table 2 below.

Table 2. Stages of a Pandemic with respect to identifying daily PPE Needs.

The range identified by the PPE needs algorithm also allows health systems and others to make policy decisions around PPE consumption. PPE supplies can be tied to an organization’s understanding of the potential viral load to which its workforce may be exposed, as well as the effectiveness and utility of PPE items, such as gowns and masks, over time.

Previous guidance on PPE consumption rate was 1 per patient. In other words, healthcare workers were advised to use new PPE for each patient they treat. This rate is not always practical and was not truly possible during COVID-19 for a number of reasons including an insufficient supply and manufacturing capability to support this level. Price surge of PPE as well as geopolitical issues and hoarding further complicated acquisition in a timely manner. Thus, to establish an upper bound for daily PPE consumption rate, given research suggests that a typical number of patients a healthcare worker sees per day is 25, this value of 25 per day was taken as an upper bound.[12] Discussions with clinicians seeing patients diagnosed with or under investigation for COVID-19 established four (4) as a reliable minimum number of times a day a healthcare worker would be likely to change their PPE.

The PPE consumption rate was established to fall between this minimum and maximum by linking consumption rate to the Transmission and Mortality Risk. With a higher risk of transmission and mortality (or critical condition due to the contagious infection), the greater the risk of COVID-19 hospitalizations, and the greater the risk of healthcare worker exposure to higher viral loads, and therefore, the higher the number of times a day they should change their PPE. Figure 1 below shows the range of daily PPE need during the Response Phase in late May 2020.

Figure 1: Visualization of Daily PPE Need at the County Level for the Response Phase. The legend suggests the possibility that a County may require 0 PPE, in practical terms, no U.S. County or territory is without need of personal protective equipment.

Who uses this Information and How?

Buyers of PPE can use this information to estimate their minimum PPE needs both overall and by specific item. With this information, they can stage the acquisition of their supplies to both ensure they don’t experience a shortage and avoid having excess PPE on hand. Such a situation means critical financial resources are tied up into supplies that could have been purchased & delivered later on. During the Pre-Pandemic Planning stage, buyers can use the risk-based PPE consumption rate to estimate a quantity of PPE that will give them enough time during the Pandemic Response stage to learn their actual PPE consumption rate. Once the actual PPE consumption rate is known, it can be integrated into the risk-based approach to further refine PPE purchasing decisions going forward. Buyers can be health systems and organizations buying on behalf of the healthcare and other industry workforce who will need PPE.

Health Department Secretaries can also estimate the need for PPE for emergency stockpiles. This opens the possibility to address a policy question: Who should receive supplies from emergency stockpiles of PPE? Healthcare and first responders typically do have access to state and federal emergency stockpiles. Should retailers? Many retailers, such as a local guitar shop, interact customers in a way that may not allow for effective social distancing. Should they need to stock PPE for their staff? If a shop chooses to not serve a customer without PPE (e.g., a mask), would they also choose to have on hand new, unused masks to offer to customers to ensure no loss of customers. Will they have to purchase these masks from the market, or in the event of an unforeseen pandemic, will the government provide PPE to retailers so they can safely open, serve their consumers, and earn a living? It is vital for manufacturers and distributors to know what production levels to target, as well as whom the potential buyers may be. Given the size of U.S. retail, this policy decision will impact supply needs and the overall buyer community.

Economic Implications

Prices have risen for PPE items through COVID-19. A N95 mask was less than $1 in 2019 and is now selling for $6.50 and up. Manufacturing PPE products locally has numerous economic benefits and opens the door for employment opportunities. If the U.S. was able to produce their own PPE, it could prevent this drastic rise in prices (especially during an emergency) since there would be multiple avenues in which healthcare organizations could purchase their PPE equipment, as well as greater opportunity for government intervention and price controls. One concern is that U.S. manufacturing is typically more expensive than manufacturing in other nations. This can be addressed through automation, government subsidies, and potentially through locating production facilities in lower cost regions of the country.[4] Additionally, increased U.S. production of PPE would decrease dependence on imports which would resolve or help avoid geopolitical issues that could arise when attempting to trade and purchase PPE with other nations.[5] Prior to the pandemic, China held 14% of the global respiratory protection market[9] and 46% of the global market for PPE production[10]. The following countries also play a role within the PPE industry: U.S., Canada, Mexico, Germany, U.K., France, Russia, Spain, Italy, India, Japan, South Korea, Indonesia, Australia, Thailand, Malaysia, Brazil, Argentina, Saudi Arabia, United Arab Emirates, and South Africa.[6] The strength of relations with these countries varies so U.S. manufacturing would offer stability and security.[7] Furthermore, increasing local production also opens the possibility of the U.S. supplying PPE products to the world – as we have done for ventilators – and gaining political advantage from having a larger share of the global PPE market.

Manufacturing PPE in the U.S. also has the potential to create jobs which would help alleviate some of the economic repercussions caused by social distancing efforts in response to the pandemic. According to the Bureau of Labor and Statistics (BLS), there were 12,852,000 manufacturing sector jobs before COVID-19, yet this number has decreased to just 11,488,000 despite the need for increased production of PPE.[6,11] The U.S. manufacturing industry and overall economy could greatly benefit from investing in their production capabilities and workforce to meet the growing global demand for PPE. Growing manufacturing capacity can bolster the economy while also providing citizens with work and income to feed their families. For instance, the food and beverage service industry employed 5,406,600 as of 2018, many of whom have lost their jobs in 2020, permanently in some cases, due to the pandemic and could potentially serve in an expanded PPE manufacturing industry.[8] Lastly, it is easier to provide oversight and ensure quality for local (national) production of PPE as compared to global production. There are limited means to ensure that products purchased from other countries are as durable and effective as those produced in the U.S.

A Buy American future for U.S. Healthcare

The suggestions and solution approach discussed here will aid health systems and states acquire the right amount of PPE to protect their clinical and broader workers, reopen the economy, and protect against the further spread and a possible future wave of COVID-19 or any contagious disease outbreak.

Figure 2: HSR CMO preparing to treat a COVID-19 patient (next step is to put on gloves).

For instance, this model can be used for the annual flu as well. It helps avoid the risk of having too little PPE on hand, and putting healthcare and other workers at risk, as well as the risk of having too large a stockpile of PPE and tying up critical financial resources that are also needed elsewhere. In addition, the analytics can guide efforts to re-establish U.S.-based production of PPE. This approach to assessing supply needs applies in general to any critical equipment – whether entire products, components, or parts deemed essential to American life. Increasing U.S. production of PPE will have lasting public health, economic, and national security benefits. Not to mention the geopolitical benefits that can accrue by reducing or fully taking back China’s hold on the medical supply industry and overall manufacturing.

The National Council of Textile Organizations is supporting a Buy American policy in healthcare to ensure a locally-produced supply of PPE for frontline healthcare workers.[3] Such a movement would mirror a policy in the U.S. military that ensures textiles for U.S. warfighters, and the supply chain that produces those textiles, are produced at home. Similar protections for medical equipment, and potentially all essential workers, is certainly an idea worth consideration.

For additional information, please contact HSR.health at 240-731-0756.

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References

1. The American Community Survey data tables produced by the US Census Bureau. (n.d.). Retrieved June 3, 2020, from https://www.census.gov/data.html
2. Occupational Data Table C24010 of the American Community Survey, U.S. Census Bureau. (2018). Retrieved June 3, 2020, from https://data.census.gov/cedsci/table?q=C24010&hidePreview=false&tid=ACSDT5Y2018.C24010&vintage=2018
3. Ellis, K. (2020, April 30). NCTO Urges Government to Institute Buy American Policy to Boost Manufacturing of Personal Protective Equipment. Retrieved June 3, 2020, from http://www.ncto.org/ncto-urges-government-to-institute-buy-american-policy-to-boost-manufacturing-of-personal-protective-equipment/
4. West, D. M., & Lansang, C. (2018, July 10). Global manufacturing scorecard: How the US compares to 18 other nations. Retrieved June 4, 2020, from https://www.brookings.edu/research/global-manufacturing-scorecard-how-the-us-compares-to-18-other-nations/
5. Artenstein, A. W. (2020). In pursuit of PPE. New England Journal of Medicine, 382(18), e46.
6. Personal Protective Equipment Market: PPE Industry Report, 2027. (n.d.). Retrieved June 3, 2020, from https://www.grandviewresearch.com/industry-analysis/personal-protective-equipment-ppe-market
7. About the Manufacturing sector. (n.d.). Retrieved June 3, 2020, from https://www.bls.gov/iag/tgs/iag31-33.htm
8. Food and Beverage Serving and Related Workers: Occupational Outlook Handbook. Accessed June 3, 2020, https://www.bls.gov/ooh/food-preparation-and-serving/food-and-beverage-serving-and-related-workers.htm.
9. Blazyte, A. (2020, March 17). China: personal protective equipment market share by product type 2019. Retrieved June 5, 2020, from https://www.statista.com/statistics/1103415/china-personal-protective-equipment-market-share-by-product-category/ 10. (n.d.). Retrieved June 5, 2020, from https://en.abrams.wiki/tools/marketintelligence?hscode=630790&from=2010-01&to=2019-12&overview=101100010
11. Data on manufacturing jobs was retrieved from the U.S. Bureau of Labor and Statistics retrieved online: https://www.bls.gov/iag/tgs/iag31-33.htm
12. 2016 Survey of America’s Physicians Practice Patterns & Perspectives. (2016). Retrieved June 5, 2020, from https://physiciansfoundation.org/wp content/uploads/2018/01/Biennial_Physician_Survey_2016.pdf
13. Personal Protective Equipment Market. (2020). Retrieved June 5, 2020, from https://www.marketsandmarkets.com/Market-Reports/personal-protective-equipment-market-132681971.html
14. Personal Protective Equipment Market Size & Outlook: PPE Market. (n.d.). Retrieved June 5, 2020, from https://www.marketresearchfuture.com/reports/personal-protective-equipment-market-3826