Shortages related to the COVID-19 pandemic

Shortages of medical materials and other goods caused by the COVID-19 pandemic quickly became a major global issue. The matter of pandemic-related shortage has been studied in the past and has been documented in recent events. On the medical side, shortages of personal protective equipment such as medical masks, gloves, face shields, and sanitizing products, were also joined by shortages of more advanced devices such as hospital beds, Intensive care unit (ICU) beds, oxygen therapy, ventilators, and ECMO (Extracorporeal membrane oxygenation) devices. Human resources, especially in terms of medical staff, may be drained by the overwhelming extent of the epidemic and associated workload, together with losses by contamination, isolation, sickness, or mortality among health care workers. Territories are differently equipped to face the pandemic. Various emergency measures have been taken to ramp up equipment levels such as purchases, while calls for donations, local 3D makers, volunteer staffing, mandatory draft, or seizure of stocks and factory lines have also occurred. Bidding wars between different countries and states over these items are reported to be a major issue, with price increases, orders seized by local government, or cancelled by selling company to be redirected to higher bidder. In some cases, medical workers have been ordered to not speak about these shortages of resources. While public health advocates and officials have encouraged to flatten the curve by social distancing, the unmitigated ICU needs would be about 50 times the available ICU beds and ventilators capacity of most developed countries. There have also been calls to increase healthcare capacity despite shortages. Background- Long term and structural: Following warnings and increased preparedness in the 2000s, the 2009 swine flu pandemic led to rapid anti-pandemic reactions among Western countries. The H1N1/09 virus strain, with mild symptoms and low lethality, eventually led to a backlash over public sector over-reactiveness, spending, and the high cost/benefit of the 2009 flu vaccine. In the following years, national strategic stockpiles of medical equipment were not systematically renewed. In France, a €382 million spending for H1N1 vaccines and masks was widely criticised. French health authorities decided in 2011 to not replace their stocks, to reduce acquisitions and storage costs, to rely more on supplies from China and just-in-time logistics, and to distribute the responsibility to private companies on an optional basis. In 2013, to save cost, a law moved responsibility for personal protective equipment (PPE) stockpiles from the French government to public and private enterprises, which had to plan the security of their workers, without any verification mechanisms in place. National manufacturers could not compete with Chinese manufacturers' prices on this new open market. The former strategic masks producer closed in 2018 while the French strategic stockpile dropped in this period from one billion surgical masks and 600 million FFP2 masks in 2010 to 150 million and zero, respectively, in early 2020. France has been called a case study of Juan Branco, author of a critical book on French President Emmanuel Macron's raise to power, argued that selfish quest of power and loyalty in leadership lead young and unexperimented people in charge of nation-wide health care reforms via blind accounting analysis and management. France has been cited as a case study for countries now considering a U-turn over the past two decades of globalisation of health supplies to gain lower immediate costs. The same approach was taken in the United States. The U.S. Strategic National Stockpile's stock of masks used against the 2009 flu pandemic was not replenished, neither by the Obama administration nor by the Trump administration. American masks manufacturer Mike Bowen of Prestige Ameritech had been warning for years that the USA mask supply chain was too dependent on China. As Juan Branco for France, Former US President Obama denounced short-term individualistic mindset as negatively affecting public decision making and preparedness. Several public (World Health Organization (WHO), World Bank, Global Preparedness Monitoring Board) and private initiatives raised awareness about pandemic threats and needs for better preparedness. Since 2015, Bill Gates has been warning about needing to prepare for a global pandemic. International divisions and lack of suitable collaboration limited preparedness. WHO's pandemic influenza preparedness project had a US$39 million two-year budget, out of WHO's 2020–2021 budget of US$4.8 billion. While WHO gives recommendations, there is no sustained mechanism to review countries' preparedness for epidemics and their rapid response abilities. According to international economist Roland Rajah, while there are guidelines, local action depends on local governance. Andy Xie, writing in the South China Morning Post, argued that ruling elites, obsessed with economic metrics, failed to prepare their communities against well-known pandemic risks. Tax systems in the early twenty-first century, by favouring the largest corporations with anti-competitive practices and lower investment rates into innovation and productions, favoured corporate actors and corporate profits, increasing the risk of shortages and weakening the society ability to respond to a pandemic. Early outbreaks in Hubei, Italy, and Spain showed that several wealthy countries' health care systems were overwhelmed. In developing countries with weaker medical infrastructure, oxygen therapy, equipment for intensive care beds and other medical needs, shortages were expected to occur earlier. Immediate: First signs and warnings were due to an abnormal viral pneumonia of unknown cause in December 2019. That month, Taiwan sent several of their Centers for Disease Control doctors to Wuhan to inspect the local situation. Following confirmation of an emerging crisis and as soon as 31 December 2019, Taiwan started to implement non-pharmaceutical measures such as travellers temperature checks, GPS tracking, connecting past-15 days travel history into its universal universal national healthcare database, closing travel lines to/from Wuhan and stockpiling personal protection equipment such as medical masks. While well informed and later lauded for its extremely efficient virus containment, Taiwan could not weigh into the World Health Organization's reactions due to mainland Chinas long-standing policy of preventing Taiwan from joining the WHO and other global organisations. Germany, another role model in the crisis, also anticipated as soon as January 2020. The United States federal government response, on the other hand, remained passive for 2 months, up to mid-March 2020, without initiating changes in their Strategic National Stockpile of medical supplies. In 2019, the Global Preparedness Monitoring Board reported the WHO's pandemic emergency fund was still depleted due to the 2018-19 Kivu Ebola epidemic. Populism, nationalism and protectionism affects geopolitics, most notably setting the two major economies on confrontational courses, leaving a leadership vacuum on the world stage. As the Wuhan outbreak spread in January 2020, China began blocking exports of N95 masks, booties, gloves and other supplies produced by factories on its territory; organisations close to the Chinese government scoured foreign markets for PPE as late as February. This created an unanticipated supply collapse for most other countries relying on it. Overstretched health services often divert resources away from services women need, including pre- and post-natal health care and contraceptives, and exacerbate a lack of access to sexual and reproductive health services. Tests: Testing shortage is a key element preventing authorities from measuring the true extent of current epidemic spread. Germany and Korea's anticipative and aggressive testing strategies has helped to reduce the measured fatality rate. Germany started producing and stockpiling COVID-19 tests as soon as January 2020. Diagnostic tests- Reagents: In Ireland and the UK, in late March and early April, reagent shortages limited the number of tests. By March, insufficient amounts of reagent became a bottleneck for mass testing in the European Union (EU), United Kingdom (UK) and the United States (US). This has led some authors to explore sample preparation protocols that involve heating samples at 98 °C (208 °F) for 5 minutes to release RNA genomes for further testing. In UK, on 1 April, the UK government confirmed that a total of 2,000 NHS staff had been tested for coronavirus since the outbreak began, but Cabinet Office Minister Michael Gove said a shortage of chemicals needed for the test meant it was not possible to screen the NHS's 1.2 million workforce. Gove's statement was contradicted by the Chemical Industries Association, which said there was not a shortage of the relevant chemicals and that at a meeting with a business minister the week before the government had not tried to find out about potential supply problems. There were also reagent shortages in the United States. Some hospitals manufactured their own reagents from publicly-available recipes. Swabs: A feared shortage of swabs in Iceland was averted when stocks were found to bridge the gap until more arrived from China. There were no swabs in the US Strategic National Stockpile, and the US had shortages, despite the one pre-pandemic domestic manufacturer increasing production to 1 million swabs per day in March, and government funding for it to build a new factory in May. Shortages also arose in the UK, but were resolved by 2 April. In-house manufacturing: The US FDA licensed a swab-free saliva test and more new swab designs, including 3-D printed versions which are now being manufactured in the labs, hospitals, and other medical facilities using the swabs. In the US, general-use nasal swabs are Class I medical devices, and are not approved by the FDA. The NIH said that they should follow FDA labelling requirements, be made in a facility registered and listed with the FDA, and pass a publicly-available safety testing protocol. The material must also be safe; an already-approved autoclavable surgical-grade plastic can be used. The full development process can take as little as two weeks. 3-D-printed swabs increased the demand for suitable 3-D printers. Some 3-D-printed swab designs are publicly-licensed under Creative Commons licenses, and others are patented, but with the 3-D printing files freely available on request to permitted facilities during the epidemic. Personal protective equipment- Generalities: Although the vast majority of PPE is produced in China, domestic supplies were insufficient. The Chinese government took control of stocks from foreign enterprises whose factories produced these goods. Medicon, whose three factories produced such supplies in China, saw their stocks seized by the Communist Party-led government. Figures from China Customs show that some 2.46 billion pieces of epidemic prevention and control materials had been imported between 24 January and 29 February, including 2.02 billion masks and 25.38 million items of protective clothing valued at 8.2 billion yuan ($1 billion). Press reported that the China Poly Group, together with other Chinese companies and state-owned enterprises, had an important role in scouring markets abroad to procure essential medical supplies and equipment for China. Risland (formerly Country Garden) sourced 82 tonnes of supplies, which were subsequently airlifted to Wuhan. Greenland Holdings also sourced bulk supplies of medical consumables such as surgical masks, thermometers, antibacterial wipes, hand sanitisers, gloves and paracetamol for shipping to China. The mass procurement of supplies at wholesale and retail levels by Chinese companies to help their compatriots back home have contributed to shortages of products in western countries where these Chinese companies operate. On 24 March the Australian Prime Minister Scott Morrison announced restrictions on such activities. Given that the global supply of PPE is insufficient, and following these Chinese measures, the World Health Organization (WHO) recommended in February 2020 minimising the need for PPE through telemedicine; physical barriers, such as clear windows; allowing only those involved in direct care to enter a room with a COVID-19 patient; using only the PPE necessary for the specific task; continuing use of the same respirator without removing it while caring for multiple patients with the same diagnosis; monitoring and coordinating the PPE supply chain; and discouraging the use of masks for asymptomatic individuals. Quality issues exacerbating shortages: In late-March/early-April 2020, as Western countries were in turn dependent on China for supplies of masks and other equipment, European politicians e.g. the EU chief diplomat Josep Borrell accused China of a soft-power play to influence world opinion. Also, some of the supplies sent to Spain, Turkey, and the Netherlands were rejected as being faulty. Dutch health ministry issued a recall of 600,000 face masks from a Chinese supplier on 21 March that did not fit properly and whose filters did not work as intended despite them having a quality certificate; The Spanish government discovered that 60,000 out of 340,000 test kits from a Chinese manufacturer did not accurately test for COVID-19. The Chinese Ministry of Foreign Affairs responded that the customer should "double-check the instructions to make sure that you ordered, paid for and distributed the right ones. Do not use non-surgical masks for surgical purposes". In mid-May, the European Commission suspended an order of 10 million Chinese masks destined for member states and the UK after two countries reported having received sub-standard products. The masks had been ordered by the EU's executive arm and was set to be distributed in six weekly instalments. After a first batch of 1.5 million masks was distributed to 17 of the 27 member states and Britain, Poland said the 600,000 items they received did not have European certificates nor did they comply with the necessary standard. Commission health spokesman Stefan De Keersmaecker vowed to investigate and take the necessary action. By April 2020, studies revealed that a significant percentage of those with coronavirus were asymptomatic, allowing the virus to spread undetected. Therefore, the CDC recommended "wearing cloth face coverings in public settings where other social distancing measures are difficult to maintain". Sanitising products: Hand sanitiser went out of stock in many areas, causing price gouging. In response, brewers and distillers began to produce hand sanitizer. Protective gear: In the United States, shortages were such that some nurses at one New York City hospital resorted to wearing garbage bags as an alternative to unavailable protective clothing. In light of the shortages of traditional protective gear, small businesses throughout the United States have been retooling to produce makeshift protective devices, often created through open source design initiatives in which manufacturers donate the gear to hospitals. An example is the COVID-19 Intubation Safety Box, first used by hospitals in Taiwan, which is an acrylic cube placed over an infected patient's torso, with openings that allow ventilator intubation and extubation while minimising contaminated droplet risk to healthcare workers. CNBC reported that E-commerce platform Amazon banned sales of N95 face masks in the name of price gouging; the shortages of N95 protective gear became even more serious. Amazon Third party Golden Tree Supply turn to Canadian E-commerce platform Shopify to keep on supplying N95 face masks to the people of United States. In March, The Doctors' Association UK alleged that shortages were covered-up through intimidating emails, threats of disciplinary action and in two cases being sent home from work. Some doctors were disciplined after managers were annoyed by material they had posted online regarding shortages of surgical masks, goggles, visors and especially gowns in many British National Health Service hospitals. On 18 April, the communities secretary, Robert Jenrick, reported that 400,000 protective gowns and other PPE were on their way to the U.K. from Turkey. One day later, these were delayed; this led hospital leaders to directly criticise the government for the first time during the pandemic. The shipment arrived at Istanbul airport en route to the U.K. two days after ministers said that the PPE would appear in the country. Only 32,000 of the order arrived (less than one-tenth), despite the NHS making a down payment to secure its arrival on 22 April. Eventually, these all had to be returned to Turkey as they did not meet NHS standards. In July, U.S. Customs and Border Protection (CBP) banned products by the Malaysia-based Top Glove and its subsidiary TG Medical due to alleged violations of workers' rights including "debt bondage, excessive overtime, retention of identification documents, and abusive working and living conditions." Most of the world's glove supply comes from Malaysia. Facial masks- Early epidemic in China: As the epidemic accelerated, the mainland market saw a shortage of face masks due to increased public demand. In Shanghai, customers had to queue for nearly an hour to buy a pack of face masks; stocks were sold out in another half an hour. Hoarding and price gouging drove up prices, so the market regulator said it would crack down on such acts. In January 2020, price controls were imposed on all face masks on Taobao and Tmall. Other Chinese e-commerce platform – JD.com, Suning.com, Pinduoduo – did likewise; third-party vendors would be subject to price caps, with violators subject to sanctions. National stocks and shortages: In 2006, 156 million masks were added to the U.S. Strategic National Stockpile in anticipation of a flu pandemic. After they were used against the 2009 flu pandemic, neither the Obama administration nor the Trump administration renewed the stocks. By 1 April, U.S.'s Strategic National Stockpile was nearly emptied. In France, 2009 H1N1-related spending rose to €382 million, mainly on supplies and vaccines, which was later criticised. It was decided in 2011 to not replete its stocks and rely more on supply from China and just-in-time logistics. In 2010, its stock included 1 billion surgical masks and 600 million FFP2 masks; in early 2020 it was 150 million and zero, respectively. While stocks were progressively reduced, a 2013 rational stated the aim to reduce costs of acquisition and storage, now distributing this effort to all private enterprises as an optional best practice to ensure their workers' protection. This was especially relevant to FFP2 masks, more costly to acquire and store. As the COVID-19 pandemic in France took an increasing toll on medical supplies, masks and PPE supplies ran low and caused national outrage. France needs 40 million masks per week, according to French president Emmanuel Macron. France instructed its few remaining mask-producing factories to work 24/7 shifts, and to ramp up national production to 40 million masks per month. French lawmakers have opened an inquiry on the past management of these strategic stocks. In the wake of the 2020 COVID-19 pandemic and widespread complaints by nurses and other health care workers about lack of N95 masks and proper protocols, National Nurses United, the largest organization of registered nurses in the United States, filed over 125 complaints with Occupational Safety and Health Administration (OSHA) offices in 16 states charging hospitals with failing to comply with laws mandating safe workplaces in which COVID-19 nurses should be provided N-95 masks. The World Health Organization (WHO) called for industry and governments to increase manufacturing by 40% to meet global demands on 3 March 2020 and they also released a document on 6 April 2020 with recommendations for the rational use of PPE. This document was intended for those in the health care and community settings, including the handling of cargo. This global PPE shortage issue soon became a subject of interest for the concerned public. Academics from the likes of Science Foundation Ireland researched how we can find a solution and avoid this shortage in the future. Simultaneously, independent initiatives and online platforms like https://PPE Needed.com PPE Needed were started to provide an immediate solution. UNICEF has also taken steppes 97 to mitigate this current risk and anticipate near-term effects of COVID-19 as well as the access to PPE suppliers. Competition for supplies: Countries such as Britain, France, Germany, South Korea, Taiwan, China, India, and others initially responded to the outbreak by limiting or banning exports of medical supplies to protect their citizens, including rescinding orders that other nations already secured. Germany blocked exports of 240,000 masks bound for Switzerland and also stopped similar shipments to the Central Bohemian Region as well. One French company, Valmy SAS, was forced to block an order for PPE to be sent to the UK, after the company's UK representative told CNN that the order had been blocked by customs officials at the French coast. Turkey blocked a shipment of ventilators bought by two regional Spanish governments from a Turkish company, citing the risk of a shortage at home in holding onto the ventilators; 116 of the ventilators were later released. As the pandemic began to worsen, governments began employing strong-arm tactics including even surreptitious means to obtain medical supplies necessary to fight the coronavirus, either through paying more cash to reroute or seizing such equipment. Slovakian prime minister Peter Pellegrini said the government was preparing cash worth 1.2 million euros ($1.3 million) to purchase masks from a contracted Chinese supplier. He then said "However, a dealer from Germany came there first, paid more for the shipment, and bought it." Ukraine lawmaker Andriy Motovylovets also stated that "Our consuls who go to factories find their colleagues from other countries (Russia, USA, France, Germany, Italy, etc) who are trying to obtain our orders. We have paid upfront by wire transfer and have signed contracts. But they have more money, in cash. We have to fight for each shipment." San Marino authorities said they arranged a bank transfer to a supplier in Lugano, Switzerland, to pay for a half-million masks to be shared with Italian neighbours. However, the truck came in empty, because one or several unidentified foreign buyers offered more instead. Germany snatched 830,000 surgical masks that were arriving from China and destined for Italy. Although Italian authorities managed to persuade Germany to release them, no one in Germany, however, found the masks they seized at all. 1.5 million face masks that were supposed to be delivered from Spain to Slovenia were seized by German agents. French guards confiscated lorries filled with 130,000 face masks and boxes of sanitisers bound for the UK in what was described as a "despicable act" by the British government. Italian customs police hijacked some 800,000 imported masks and disposable gloves that were about to be sent to Switzerland. On 22 March, an Italian newspaper said that the 680,000 face masks and ventilators it ordered from China were confiscated by the Czech Republic's police. They carried out an anti-trafficking operation in which they seized equipment from a warehouse of a private company in northern town of Lovosice. According to Czech authorities, the donation from China represented only just over 100,000 masks. Czech government sent 110,000 items to Italy as compensation. It's unclear how the masks ended up in Lovosice. Czech Foreign Minister Tomáš Petříček told AFP: "Lovosice is not quite en route from China to Italy." Valérie Pécresse, regional counselor of Île-de-France, alleged that some Americans, in their aggressive search for stocks, had made tarmac bids for stocks of masks – sight unseen – awaiting loading onto transporters, paying 3 times the price in cash. However, Politico Europe reported the French claim as "unsubstantiated" and the U.S. Embassy in Paris stated that "The United States government has not purchased any masks intended for delivery from China to France. Reports to the contrary are completely false." On 3 April, Berlin politician Andreas Geisel accused U.S. agents of appropriating a shipment of 200,000 3M-made face masks meant for Berlin police from the airport in Bangkok. However, these claims were proven false, as 3M revealed it "has no records of an order for respiratory masks from China for the Berlin police" and Berlin police later confirmed that the shipment was not seized by U.S. authorities, but was said to have simply been bought at a better price, widely believed to be from a German dealer or China. This revelation outraged the Berlin opposition, whose CDU parliamentary group leader Burkard Dregger accused Geisel of "deliberately misleading Berliners" in order "to cover up its own inability to obtain protective equipment". FDP interior expert Marcel Luthe said "Big names in international politics like Berlin's senator Geisel are blaming others and telling US piracy to serve anti-American clichés." Politico Europe reported that "the Berliners are taking a page straight out of the Trump playbook and not letting facts get in the way of a good story." The Guardian also reported that "There is no solid proof Trump nor any other American official approved the German heist". On 3 April, Jared Moskowitz, head of Florida Division of Emergency Management, accused the American company 3M of selling N95 masks directly to foreign countries for cash instead of the United States. Moskowitz stated that 3M agreed to authorise distributors and brokers to represent they were selling the masks to Florida, but instead his team for the last several weeks "get to warehouses that are completely empty." He then said the 3M authorised U.S. distributors later told him the masks Florida contracted for never showed up because the company instead prioritised orders that come in later, for higher prices, from foreign countries (including Germany, Russia, and France). As a result, Moskowitz highlighted the issue on Twitter, saying he decided to "troll" 3M. Forbes reported that "roughly 280 million masks from warehouses around the U.S. had been purchased by foreign buyers on 30 March 2020 and were earmarked to leave the country, according to the broker – and that was in one day", causing massive critical shortages of masks in the U.S. Using the Defense Production Act, the Trump administration ordered 3M to stop selling US-produced masks to Canada and Latin America, a move the company said would cause "significant humanitarian implications" and could cause those countries to retaliate, resulting in a net decrease of supplies in the US. On 3 April, the Swedish health care company Mölnlycke announced that France had seized millions of face masks and gloves that the company imported from China to Spain and Italy. The company's general manager, Richard Twomey, denounced France for "confiscating masks and gloves even though it was not its own. This is an extremely disturbing, unbecoming act." Mölnlycke estimated a total of "six million masks was seized by the French. All had been contracted for, including a million masks each for France, Italy and Spain. The rest were destined for Belgium, the Netherlands, Portugal and Switzerland, which has special trading status with the EU." Sweden's foreign ministry stated to Agence France-Presse that "We expect France to promptly cease the requisition of medical equipment and do what it can to ensure that supply chains and the transportation of goods are secured. The common market has to function, particularly in times of crisis." On 24 April, San Francisco Mayor London Breed complained that her city's orders for PPE were diverted to other cities and countries. She said "We’ve had issues of our orders being relocated by our suppliers in China. For example, we had isolation gowns on their way to San Francisco and they were diverted to France. We’ve had situations when things we’ve ordered that have gone through Customs were confiscated by FEMA to be diverted to other locations." Trade in medical supplies between the United States and China has also become politically complicated. Exports of face masks and other medical equipment to China from the United States (and many other countries) spiked in February, according to statistics from Trade Data Monitor, prompting criticism from the Washington Post that the United States government failed to anticipate the domestic needs for that equipment. Similarly, The Wall Street Journal, citing Trade Data Monitor to show that China is the leading source of many key medical supplies, raised concerns that US tariffs on imports from China threaten imports of medical supplies into the United States. Reuse of masks: Shortage in single-use medical mask and field reports of reuse lead to the question of which process could properly sanitise these PPE without altering their filtering capacity. FFP2 masks can be sanitised by 70 °C vapour allowing reuses. Use of alcohol is discouraged since it alters N95 mask microfibres' static charge which helps filtration. Chlorine is also discouraged since its fumes may be harmful. Authors are warning against reuses by non-professionals, pointing out that even the best scored methods can degrade the mask if not performed properly. A Singaporean study found no contamination on mask after brief care to COVID-19 patients, suggesting masks could be reused for multiple patients cares. A portion of SARS-CoV-2 virus can survive long exposure to 60 °C. Makers have designed Arduino-controlled disinfection boxes, with temperature controls, to safely reuse surgical and N95 masks. Gas disinfection allows 10 reuse. DIY masks: Following N95 masks shortages, volunteers created 3D printed "NanoHack" alternative. This printed mask allows to use hand-cut surgical mask as fine-particle filters. Given the scarcity of masks and ambiguity on their efficiency, individuals and volunteers have started to produce cloth masks for themselves or for others. Various designs are shared online to ease creation. Medical face shield: Reacting to shortage of face shield, volunteers from the maker community with 3D printing abilities initiated an effort to produce face-shields for hospital staff, police, nursing home staff and other frontline workers. In total, people from 86 countries engaged in the voluntary production of PPE to supplement traditional supply chains - many of which had been interrupted. They collectively produced a total of at least 25 million face shields with techniques including 3D printing, Laser cutting, and Injection molding. 3D printer manufacturers: At the early stage, a few 3D printer manufacturers published their designs. On 14 March, Budmen Industries, a custom 3D printer maker in New York, created a face shield design and produced their first 50 shields with a plan to donate to the Onondaga County to use in a COVID-19 testing site. The company published their design and it had more than 3,000 downloads within a week. By the end of the month, the company and its partner made 5,000 face shields with global requests for 260,000 units. On 16 March, Prusa Research, a Czech 3D printer manufacturer, started working on a face shield design for medical use . The design was approved by the Czech Ministry of Health and went to a field test and a large scale production within 3 days. The company published the design for people to make face shields to support local efforts. The design was downloaded in a large number by makers around the world. By the end of March, the company employed 500 employees to work on the 10,000 shields order. Their design was downloaded 40,000 times. Local volunteers: As the shortage of personal protective equipment in New York City hospitals got into a critical stage, volunteers started making face shields using the Budmen design on 20 March. More efforts were started by various groups from hobbyists and academics to experts. Many designs had been created and groups were formed to supply face shields to local hospitals. On 24 March, while the epidemic was expanding, popular French 3D maker and YouTuber Heliox announced on 24 March that she would produce face shields for free, building upon another maker's design. She was quickly contacted by local hospitals, health centres and other medical professionals asking for rapid delivery of face shields. The visible popularity of her initiative caused other 3D makers to join the effort and offer their help in other regions to connect health facilities with nearby makers. On 30 March, The New York Times published a video on COVID-19-related shortages and healthcare workers' DIY solutions. Government agencies: On 23 March 2020, United States Food and Drug Administration (FDA), United States Department of Veterans Affairs (VA), and National Institutes of Health (NIH) entered into a memorandum of understanding to form a public-private partnership with America Makes, a non-profit organization, to test designs of 3D printed personal protective equipment including face shields. The agreement was to have NIH to provide the 3D Print Exchange system to solicit open designs, VA to perform testing in clinical settings, FDA to participate in the review process and America Makes to coordinate with makers to produce the approved designs for healthcare facilities. As of 18 June 13 face shields have been reviewed as appropriate for clinical use. On 9 April 2020, FDA issued an emergency use authorization that included an authorization for the use of face shields by health care personnel. FDA laid out the details of the conditions, and waiver of requirements for face shield makers in a letter on 13 April 2020. Companies: Apple Inc. announced on 5 April they would produce 1 million face shields per week to be sent to U.S. hospitals. By mid April, many large companies such as Hewlett-Packard, Ford Motor Company, and Blue Origin had joined the efforts to make face shields. Even sports equipment manufacturers such as Bauer Hockey joined in and started making face shields for medical workers. Medical care devices: The availability of critical care beds or ICU beds, mechanical ventilation and ECMO devices generally closely associated with hospital beds has been described as a critical bottleneck in responding to the ongoing COVID-19 pandemic. The lack of such devices dramatically raises the mortality rate of COVID-19. Oxygenation mask: Popular snorkelling masks have been adapted into oxygen dispensing emergency respiratory masks via the usage of 3D printed adapters and minimal modifications to the original mask. According to Italian laws relative to medical cares where the project has occurs, usage by the patient requires a signed declaration of acceptance of use of an uncertified biomedical device. The project provides the 3D files for free, as well as 2 forms to register hospitals in need and 3D makers willing to produces adapters. In France, the main sportswear and snorkelling masks producer Decathlon has locked down its mask sales to redirect them toward medical staff, patients and 3D makers. An international collaboration including Decathlon, BIC, Stanford, and other actors is on track to scale up production for international needs. The maker group Plan B in Romania produced more than 2,000 modified snorkeling masks to combat the pandemic. Intensive care beds: Both rich countries and developing countries have or will face intensive care beds shortages, but the situation is expected to be more intense in developing countries due to lower equipment levels. In early March, the UK government supported a strategy to develop natural herd immunity, drawing sharp criticism from medical personnel and researchers. Various forecasts by Imperial College COVID-19 Response Team, made public on 16 March, suggested that the peak number of cases in the UK would require between 100 and 225 CCBs / 100,000 inhabitants, if proper mitigation or no mitigation strategies are put into force, respectively. These requirements would both exceed the UK's current capacities of 6.6–14 CCB / 100,000 inhabitants. In the best case scenario, the peak caseload would require 7.5 times the current number of available ICU beds. Around 16 March, the UK government changed trajectory toward a more standard mitigation/suppression strategy. In France, around 15 March, the Grand Est region was the first to express the scarcity of CCB limiting its handling of the crisis. Assistance-publique Hôpitaux de Paris (AP-HP), which manages most hospitals in the French capital area (~10 million inhabitants), reported the need for 3,000–4,000 ICUs. Current capacity is reported to be between 1500 and 350, depending on the source. In France, given shortages of ICU hospital beds in Grand Est and Ile-de-France regions, severe but stable patients with ARS and breathing assistance have been moved toward other regional medical centers within France, Germany, Austria, Luxembourg, or Switzerland. Mechanical ventilation: Mechanical ventilation has been called "the device that becomes the decider between life and death" for COVID-19 patients because 3.2% of detected cases need ventilation during treatment. Ventilators shortage is endemic in the developing world. In case of shortage, some triage strategies have been previously discussed. One strategy is to grade the patient on dimensions such as: prospects for short-term survival; prospects for long-term survival; stage of life-related considerations; pregnancy and fair chance. The frequent 15 to 20 day duration of the intubation to recover is an important factor in the ventilator's shortage. An important way of reducing demand for ventilators is the use of CPAP devices as a first resort. For this reason CPAP devices themselves have become a scarce item. Official assessments: In the 2000s, the U.S. CDC estimated a national shortage of 40–70,000 ventilators in case of pandemic influenza. From this assessment resulted Project Aura, a public-private initiative to design a frugal, $3,000 mechanical ventilator, simple to mass-produce, and able to supply the Strategic National Stockpile. Newport Medical Instruments was granted the contract, designing and prototyping (2011) the frugal ventilators to CDC officials, and expecting to later profit from the product by moving into the private market where competing devices were sold for $10,000. In April 2012, US Health and Human Services officials confirmed to the US Congress that the project was on schedule to file for market approval in late 2013, after which the device would go into mass-production. In May 2012, US$12 billion medical conglomerate Covidien, a top actor of the mechanical ventilation market, acquired Newport for $100 million. Covidien soon asked to cancel the Project Aura contract since it wasn't profitable enough. Former Newport executives, government officials and executives at rival ventilator companies suspect Covidien acquired Newport to prevent the frugal $3,000 ventilator design from disturbing its profitable ventilation operation. Covidien merged in 2015 into Medtronic. Project Aura looked for and then signed a new contract with Philips healthcare. In July 2019, the FDA signed for 10,000 units of their Trilogy Evo portable ventilator, to be delivered to the SNS by mid-2020. On 25 March 2020, Andrew Cuomo made a detailed 1-hour COVID-19 press conference, emphasising an expectation of a severe shortage of ventilators, and their importance in sustaining life in severe COVID-19 cases. Cuomo said New York state would ultimately need about 30,000 ventilators to handle the influx, while having only 4,000 as of 25 March; on the 27th, President Trump expressed doubt about the need, saying "I don't believe you need 40,000 or 30,000 ventilators," and resisted calls to force businesses to produce them. Later on the 27th, the President acceded to calls to assist states in ventilator procurement, using the Defense Production Act, although fears remain that procurement will not happen in time to prevent severe shortages. Industrial suppliers: In Europe, the company Löwenstein Medical producing 1500 ICU-level ventilators and 20,000 home-level ventilator per year for France alone, pointed out of the current high demand and production shortage. Based in Europe, all their components are European and not relying on the Chinese supply chain. As for production ramp-up, it was suggested to increase the production of home-level ventilators, more basic and which can be assembled in half an hour, yet able to support patients through acute respiratory distress syndrome. The current bottleneck is mainly a question of qualified human resources. In business as usual, ICU-level ventilators are to be renewed every 10 to 15 years Due to the coronavirus pandemic, Germany and other European countries have started to take control over the company's supply. In China, local manufacturers are racing to answer the demand. Medtronic made ventilator design specifications publicly available but licensing questions remain unclarified. Improvised ventilators: In the United Kingdom, despite a lack of ventilators being previously identified in Exercise Cygnus, there was a shortage of them during COVID-19 with the government stockpiles proving to be insufficient. In March, the British government called for industry to get involved with making ventilators for the NHS, with Dyson and Babcock revealing plans on creating 30,000 medical ventilators (this amount was seen as necessary based on modelling from the time from China). The Ventilator Challenge involved companies such as Airbus, Rolls-Royce and Ford. This was seen as impractical at the time; the type of ventilators suggested by the government to these companies were crude and would not have been able to be used in hospitals, and none of the companies involved reached the final stages of testing and the majority have proved surplus to requirements in hindsight. 3D makers have been working on various low-cost alternative ventilation devices or adaptations. Open Source Medical Supplies lists open source ventilator standards and requirements on its project library, but no individual projects have been published through the library. Anesthetist Dr. Alan Gauthier from Ontario, Canada, turned one single-patient ventilator into a nine-patient device thanks to a 2006 YouTube video by 2 doctors from Detroit. The method uses T-shaped tubes to split airflow and multiply the number of patients provided with respiratory support. In Ireland, volunteers started the Open Source Ventilator Project in collaboration with medical staff. In Italy, a local journalist and journal director Nunzia Vallini of the Giornale di Brescia (Brescia Daily) was informed that nearby Chiani hospital was running out of valves which mix oxygen with air and are therefore a critical part of reanimation devices. The valves supplier was itself out of stock leading to patient deaths. Vallini contacted FabLab founder Massimo Temporelli, which invited Michele Faini, an expert in 3D print manufacturing and a research and development designer at Lonati SpA to join a 3D printing effort. When the supplier didn't wish to share the design's specifics, they reverse-engineered the valves and produced a limited not-for-profit series for local hospitals. To satisfy biomedical requirements that can withstand periodic sanitation, Lonati SpA used their SLS 3D printers to print about 100 valves in Nylon PA12. Faini and Temporelli still acknowledge the limitations of their production: 3D printing not being able to reach the quality and sterilised context of the original valves and manufacturing process.[174] Contrary to rumours online, the valves don't cost US$10,000 each and the original manufacturer did not threaten to sue the 3D printers team. Ventilator splitter valves were considered as last-resort backups in different hospital systems, and multiple designs have been reviewed by medical professionals and were published on the OSMS library. Hackers of the Ventilator Project have brainstormed to propose to re-purposing CPAP machines (sleep-apnea masks) as ventilators, hacking single ventilators to split air-flow and treat multiple patients, and using grounded aircraft as treatment facilities to leverage their one-oxygen-mask-per-seat infrastructure. Engineers familiar with devices design and production, medical professionals familiar existing respiratory devices and lawyers able to navigate FDA regulations if the needs arise are key participants among the 350 volunteers involved. The central avenue of exploration is to ditch away from the most advanced features of modern mechanical ventilation, which includes layers of electronics and patients monitoring systems, to focus solely on assisted respiration by pressured airflow. The group is, by example, looking for an old Harry Diamond Laboratories "emergency army respirator" model to study. While hopeful they will be able to submit the viable and mass-producible design, several questions linger at this later levels: mass production line, FDA approval, personnel training, personnel availability, and eventually actual needs on the battlegrounds to come. An MIT team has designed an emergency ventilator. ECMOs: Extracorporeal membrane oxygenation are devices able to replace both the lungs and the patient's heart. As of 6 February 2020, the medical community was encouraged to set up criteria for ECMO patients triage. Facilities- Hospitals: As Wuhan's situation worsened and to assist the overwhelmed Central Hospital of Wuhan and Dabie Mountain Regional Medical Centre, China built two emergency field hospitals within a few days: the Huoshenshan Hospital and Leishenshan Hospital. The hospitals were progressively phased out in March 2020. On 23 March, Lieutenant General Todd T. Semonite, Chief of the U.S. Army Corps of Engineers, signaled an ongoing effort to lease existing facilities such as hotels, college dormitories, and a larger hall to temporarily convert them into medical facilities. On 16 March, French President Emmanuel Macron announced a military hospital would be set up in the Grand-Est region, to provide up to 30 ICU beds. The hospital was being tested 7 days later. By 8 March, Lombardy had created 482 new ICU beds. Lodi's ICU director reported that every single square metre, every single aisle of the hospital had been re-purposed for severe COVID-19 patients, increasing ICU beds from 7 to 24. In Monza, 3 new wards of 50 beds each were opened on 17 March. In Bergamo, gastrology, internal medicine, neurology services have been repurposed. In the UK, almost the entire private health stock of beds was requisitioned, providing an additional 8,000 beds. Three Nightingale hospitals were created by NHS England, with the military, to provide an additional 10–11,000 critical care beds, another 1,000-bed hospital created in Scotland, and a 3,000-bed hospital at the Principality Stadium in Cardiff. Temporary wards were constructed in hospital car parks, and existing wards re-organised to free up 33,000 beds in England and 3,000 in Scotland for COVID-19 patients. A hangar at Birmingham Airport was converted into a 12,000 body mortuary. Morgues: New York morgue shortages led the city to propose temporary burial in parks. Health workers: There are many factors to the healthcare worker shortage. First, the excess demand due to the pandemic. Second, the specialized nature of care of the critically ill and the time taken to train for new methods of working to prevent cross-contamination, in some cases with new types of protective equipment (PPE). The third factor is the loss of staff to the pandemic, mostly because they are self-isolating with symptoms (which may be unrelated) or because a household member has symptoms, but also because of long term effects of the disease, or death. This last case applies across the health system and makes it harder to draw staff from non-COVID health workers. Mitigations being used include recruiting military and sports medics, final-year doctors in training, private sector staff, and re-recruiting retired staff and those who have moved from the medical sector. For non-medical roles, staff have been recruited from other sectors. Also, automation in health care (process automation solutions, AI-driven medical technologies,...) can help to reduce medical staff and some equipment such as augmented reality headsets (Microsoft HoloLens, ...)) may also help to reduce the possibility of medical staff becoming ill and unable to work an can also reduce the amount of medical staff requirements through labor efficiency gains. Patient overload: Facing the prospect of an unmanageable influx of patients both in his city and in others across the United States, New York City mayor Bill de Blasio called on the U.S. federal government to recruit additional medical staff to help meet demand. He suggested recruiting from a pool that includes retired doctors and nurses, private surgeons, and others not actively tending to COVID-19 patients, and he proposed assigning and reassigning them as needed to different parts of the country depending on which cities and states were expected to be hardest hit at any given point in time. Isolation and trauma: As for China, medical staff are self-isolating from families and under high emotional pressure. Psychological trauma is expected among medical professionals. The AMA has created a guide for healthcare organizations to reduce psychosocial trauma and increase the likelihood of medical staffs. Sickness and death: In Italy, at least 50 doctors have died from COVID-19. In Lombardy, Italy, with the mid-March 2020 outbreak, medical staff reported high level of sick staff. In Lodi, doctors from other services have been called to attend Covid patients. In Cremona, the number of patients entries was three times the usual while services were running with 50% of their staff. On 12 March 8% of Italy's 13,382 cases were health workers. It was also reported that between 5 and 10% of deaths were medical staff. On 17 March, one of the largest hospital of the Bergamo region ran out of ICU beds, patients were flown to other regions by helicopter. About 14% of Spanish cases are medical staff. USA, about 62,000 HCW have been detected as infected by late May 2020, 291 have died (0.47%). By late May, Mexico had 11,000 medical staff detected as infected, depleting medical ranks. Industrial products: Shortages of propane, attributed to reduced petroleum production from depressed travel demand during the pandemic, were cited as potentially affecting agricultural production. The pandemic has led to increased consumer demand for propane because more people were staying at home during winter, increasing the need for domestic heating and cooking. In the United States, shortages of propane have been reported in Kentucky, Louisiana, and Wisconsin. General Motors was forced to halt production at several facilities across North America due to a shortage in semiconductors. Pharmaceutical products: Critical inhaler medication shortage loomed as coronavirus cases soared in March 2020. Consumer goods: Some daily goods have seen shortages as a result of both disruptions to the supply chains and spikes in demand., leading to empty shelves for these products in grocery stores. Affected products included toilet paper, hand sanitiser, cleaning supplies, canned food. Various consumer items were reported in local shortage due to either supply chain disruption or unusual demand, including freezers, $100 bills (on one bank in New York City), jigsaw puzzles, Kettlebells, blood, baking yeast, dogs and cats for adoption in New York City, PlayStation 4, Nintendo Switch and Nintendo Switch Lite, and laptop and tablet computers. There has been a global shortage of bikes due to high demand for both recreational use and commuting as public transport was shut down in many places due to the pandemic. The problem was exacerbated by the associated decrease in manufacturing in Asia and Europe. Small gold bars and gold coins faced a shortage in mid 2020 due to both increased demand for gold as a stable investment, and as a result of some refineries and mints ceasing operation due to lockdowns. Condoms: In late March and early April, concerns about a global condom shortage arose after some factories that manufacture condoms were forced to shut down or reduce their operations, in compliance with government-imposed stay-at-home orders, including Malaysia-based Karex, the world's largest condom producer. This has been compounded with delays in delivery due to greater restrictions on imports and freight, such as Egypt's 18-day quarantine on condom shipments. The possibility of a condom shortage has been particularly concerning for groups focused on contraception and HIV prevention in Africa. Toilet paper and other paper products: The pandemic led to shortages of toilet paper in various countries, including Australia, Singapore, Hong Kong, Canada, the United Kingdom, and the United States. In March 2020 at numerous stores throughout these countries, shoppers reported empty shelves in both the toilet paper section as well as sections for related products such as paper towels, tissues, and diapers. Initially, much of this was blamed on panic buying. Consumers began fearing both supply chain disruption and the possibility of being forced into extended quarantines that would prevent them from purchasing toilet paper and related products, despite reassurance from industry and government that neither was likely to occur. As a result, some consumers began hoarding toilet paper, leading to reports of empty shelves, which in turn led to additional fear of a toilet paper shortage that prompted others to hoard toilet paper as well. The shortage created a massive spike in Google Search, over 4000% for the term "toilet paper" alone. Essential supply locator sites and tools sprouted up everywhere in an effort to assist communities in finding local sources as online retailers were out of stock. However, by early April 2020, additional factors other than panic buying were identified as causes of the toilet paper shortage. In particular, as a result of stay-at-home orders, people have been spending much less time at schools, workplaces, and other public venues and much more time at home, thus using public toilets less frequently and home toilets more frequently. This has caused a strain on supply chains, since public toilets and home toilets generally use two different grades of toilet paper: commercial toilet paper and consumer toilet paper, respectively. Georgia-Pacific predicted a 40 percent increase in the use of consumer toilet paper as a result of people staying at home. Due to differences in roll size, packaging, and supply and distribution networks between the two grades, toilet paper manufacturers are expected to have difficulty shifting production to meet the shift in demand from commercial to home use, leading to lingering shortages even after panic buying subsides. There has also been an increase in the sale of bidets. Aluminum cans: The shift of the consumption of beverages from public places to homes created an Aluminum can shortage in the United States. Others: In France, due to closed borders preventing foreign seasonal workers from entering the country, the Minister of Agriculture called for jobless volunteers to contact strawberry farms to help collect the harvest for the usual minimal wage. Laboratory mice are being culled, and some strains are at risk of shortage due to lockdowns. In the United States, social distancing has led to shortages of blood donations. Pepperoni shortages occurred in the United States that increased the price of Pepperoni by 50%. American restaurants have experienced Ketchup shortages. Coins: A shortage of coins was also reported around the United States as the circulation of coins came to a halt. The normal circulation of coins through banks, business, and consumers was interrupted at every step. The lockdown closed both banks and businesses. Consumers also shied away from the use of cash when health warnings from the WHO, NIH, and CDC indicated that the use of cash and coin could spread the virus. Therefore, coins stopped moving throughout the economy. The shortage was further exacerbated when the United States Department of the Treasury authorized the minting of fewer coins earlier in the year to protect workers during the pandemic. Guns and ammuniton: As a result of the COVID-19 pandemic in the United States and the civil unrest within the country, many people reported a shortage of guns and ammunition as a result of panic buying with many gun shops and retailers limiting how much ammunition one may purchase.