Less than a week after diagnosed cases of COVID-19 grew rapidly in the Seattle area, health care providers say medical supplies are growing scarce, threatening to further stress a system already scrambling to control the coronavirus outbreak.

The state Department of Health (DOH) has confirmed 79 cases of the disease in four counties, and as of midday Friday, at least 15 deaths have been linked to the illness in Washington.

Now, as global supply chains have been disrupted and the number of cases climbs, health authorities are hunting for medical supplies and have called on employees to ration.

“Limit mask use to on the patient only,” read a Wednesday email from a Valley Medical Center (VMC) staffer to nurses, referring to surgical masks. “Staff will no longer wear masks, unless providing a care procedure requiring removal of the patient’s mask.”

According to the email: “Masks are in critical supply” and that “due to disaster conditions VMC will be implementing alternate standards of care to conserve masks for critical and surgical use.”

About an hour after the message went out, staff objected and it was retracted, according to Liz Nolan, a VMC spokeswoman, and the hospital found other ways to conserve and nurses were allotted one mask per shift.

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Several Seattle-area medical centers have lowered the protocol for levels of precaution health workers take with personal protective gear when treating confirmed or suspected COVID-19 patients.

“This is a global issue,” said Dr. Christopher Baliga, chief of infectious disease at Virginia Mason Medical Center, of the supply problem.

The supply shortages in Seattle highlight what health experts identify as COVID-19’s threat: That regional surges of medical needs stress a nationwide system that experts say operates close to capacity even when there’s not a crisis.

“We run really close to the bone,” said Julie Fischer, an associate research professor in the Department of Microbiology and Immunology at Georgetown University Medical Center. “Our systems are pretty fragile. They don’t have a lot of slack, a lot of room, for surging over a long period of time.”

Supply shortages vary from facility to facility.

“We have more than enough gloves, masks, gowns … I haven’t had any kind of supply issue,” said a member of the SEIU Healthcare 1199 NW, who is a health care worker at EvergreenHealth, in Kirkland, where 12 COVID-19 patients have died.

Meanwhile, nurses elsewhere said they were frightened by reports of low stock.

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“It’s scary. There’s a lot of staff concerned and questioning,” said Chris Lopez, a VMC charge nurse who works in general medicine, where he said he could interact with potential COVID-19 patients awaiting screening.

Lopez said he’s heard from many upset coworkers.

“They have friends who work at other places. They’re being told that’s not happening there,” Lopez said.

At Virginia Mason Medical Center, “we have already run out of critical supplies,” said Baliga on Friday morning, but added that the hospital had not run out of anything for which it did not have a contingency plan.

“If the number of patients we’re admitting to the hospital increases, and by all accounts we do expect it to increase, we’ll run into real operational issues,” he said.

Baliga said N-95 respirator masks, patient gowns and hand sanitizer are in short supply.

Many Virginia Mason frontline health care workers treating suspected or confirmed COVID-19 cases, he said, are using a reusable Powered Air Purifying Respirator (PAPR) system with a hood to protect doctors, nurses and others against infection.

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The systems can be cleaned, and hospital management has “emphasized the reusability” of that equipment, Baliga said. “Don’t throw them away.”

UW Medicine also said it was “closely monitoring its supply of masks and other personal protective equipment,” hospital spokeswoman Susan Gregg said in an email Thursday afternoon.

“… Use of personal protective equipment has increased dramatically,” Gregg said. “At this time, we have an adequate, though decreasing, supply and are working with our vendors to ensure that we will continue to receive needed supplies.”

At Harborview Medical Center, Olga Ramirez, a nurse and SEIU Healthcare 1199 NW executive board member, said her workplace was properly outfitted, for now.

“It’s starting to increase more and more,” Ramirez said of the virus.

“I’m human, too — it does make me nervous,” Ramirez said. “I have underlying health care issues. I have asthma, I have diabetes and some heart problems. So, I’m concerned that going to work is going to somehow affect me medically, physically, mentally.”

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She said she worried she would end up “in a hospital bed.”

In Wuhan, China, more than 2,000 healthcare workers have been sickened by the virus, according to a report from the World Health Organization.

Most of their illnesses were identified early in the outbreak when supplies were low and when the understanding of the disease was lower, the report said. Some workers likely contracted the virus outside of work, too.

Fischer said workers there were often working long hours without backup or relief.

“When you see people have exposures … it’s when they’re working long hours and when they’re under enormous amounts of stress,” Fischer said.

UW Medicine on Wednesday dropped its level of precaution for health care workers interacting with COVID-19 patients, or those suspected of infection, from “airborne precautions,” in which respirators — such as N95 respirators or PAPR system — are required, to “droplet precautions.”

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Respirators would still be used for patients who are critically ill or undergoing aerosol-generating procedures, like intubation.

Under this protocol, workers must use standard surgical masks and eye protection to guard against respiratory droplets from coughs or sneezes.

The Centers for Disease Control and Prevention (CDC), as of Friday evening, advises health centers to use “airborne precautions,” but the WHO advises the use of “droplet precautions.”

Swedish, Kaiser Permanente and MultiCare medical centers are using the “droplet precautions” too, Gregg said. The Washington State Department of Health said in a letter to health care providers it supports the practice.

Fischer, of Georgetown, said the CDC guidance is conservative. In the U.S., where health care workers have access to equipment, “it’s better to advise the most comprehensive protection necessary,” Fischer said.

She added that data about the virus is incomplete and with more information, health care providers will get more accurate risk assessments.

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“The biology of the virus suggests workers should be protected in most cases through droplet precautions,” Fischer said, adding that hospitals should have managers in charge of infection prevention who assess risk to frontline workers and make sure they have adequate training and equipment.

“The scarcest commodity and the most precious commodity we have are people,” Fischer said.

Baliga said the protective measures the CDC proposes work when providers have a handful of patients, but “it can’t be done in a community outbreak. We don’t have the supply. We don’t have the rooms.”

Baliga on Friday morning said Virginia Mason has double or triple the patients requiring airborne precautions than usual, and could choose to lower to droplet precautions to keep up with demand.

Slow testing exacerbates equipment problems, Baliga said. With suspected COVID-19 cases, “our staff are treating them as if they have it until we know they don’t,” which means higher levels of precaution, requiring more health workers using more gear.

The longer the wait for test results, the more equipment is used on cases that don’t turn out to be COVID-19.

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Washington state officials on Feb. 29 asked the federal government to provide state health care workers more equipment from the National Strategic Stockpile, a U.S. Department of Health and Human Services program that holds medical supplies to supplement local stocks during public health emergencies.

The Department of Health asked for 233,280 N95 respirators, 200,000 surgical masks and 60,000 disposable gowns, according to a copy of the order.

“We requested this based on the needs we had at the time of the need,” said Casey Katims, Director of Federal and Inter-State Affairs for Gov. Jay Inslee.

The federal government agreed to supply half of the request within 24 hours, Katims said.

Then, state officials had to ask again for the full order.

The second half of the supplies was delivered overnight and into Friday morning, Katims said.

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The state needs more.

“We intend to request additional … protective equipment from the national stockpile and we intend to submit that to the administration later today,” Katims said Friday afternoon.

Global demand has stretched supplies of key equipment, like N95 respirators.

“STOP BUYING MASKS!,”  U.S. Surgeon General Jerome Adams said in a Saturday tweet, as people who were not medical personnel rushed to buy them.

Baliga said the supply chains for health care products are global and interconnected, which has caused problems, as China and other parts of the world were hit by the new coronavirus.

“You have major manufacturers being heavily impacted by the virus. You also have the fact that every hospital and health care system in the world is trying to prepare for this,” Baliga said.

The company 3M manufactures millions of respirators at facilities in the United States, China and Latin America, according to a Monday news release.

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3M’s South Dakota plant has been “running around the clock in response to the coronavirus outbreak — and the resulting global demand for respirators.”

On Wednesday, the U.S. Department of Health & Human Services announced it intends to buy some 500 million N95 respirators over the next 18 months, aiming to spur manufacturers to produce more respirators.

There are about 13 million N95 respirators in the stockpile now, said Stephanie Bialek, Stockpile Communication Services Section Chief.

When China locked down Wuhan, in an extreme and Draconian measure to constrain the coronavirus, “they bought us time to prepare,” Fischer said, noting that the measure made it difficult to provide areas of Wuhan with critical supplies.

Fischer said we have to “think creatively” in the U.S. about how we use the resources and supplies available and how to manage stress on the health care workforce as the outbreak expands.

“The more communities that need support, the more stress we’re putting on the federal system,” Fischer said. “Those resources are not infinite.”

She added: “What you’re seeing happening in Seattle is the hard decisions.”

Seattle Times reporter Elise Takahama contributed to this report.

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