Paying the Price for PPE
By Sean Price Texas Medicine June 2020

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Editor’s Note: Texas Medicine first published a version of these stories in Texas Medicine Today in April. Although circumstances may have changed, we republish them to give you a snapshot in time of this critical aspect of the COVID-19 crisis.

The early days of the COVID-19 pandemic threw the market for personal protective equipment (PPE) into chaos. So physicians and county medical societies across Texas found they had to go big or go home when it came to obtaining those critical supplies.

County Society Exec “Literally Meeting With People in Parking Lots” to Get PPE for Physicians

Companies selling masks often ignored small, private orders from individual physicians, or pushed them so far into the future they were useless, said Javier Vazquez, executive director of the Cameron-Willacy County Medical Society in the Rio Grande Valley. So physicians pooled their resources through county medical societies to buy bulk shipments of N95 respirators, face shields, gloves, and other equipment.

Even then, obtaining PPE wasn’t easy, Mr. Vazquez said.

“It had taken us at least two weeks to secure a legitimate order for legitimate masks, and our officers were getting anxious about not having anything on hand,” he said.

U.S. physicians were anxious because they likely needed up to 3.5 billion N95 masks to handle a pandemic respiratory virus, while normal U.S. production is around 1.5 billion, according to a 2017 report in the journal Health Security.

State officials had encouraged physicians to follow their normal channels for obtaining PPE, but that was difficult in part because some PPE vendors seemed to be trying to defraud buyers, Mr. Vazquez said. Some deliberately tried to sell fake or inferior-grade masks while others didn’t know one type of PPE from another.

“I was literally meeting with people in parking lots [to determine if masks were real or not],” he said. “It looked almost like a Godfather scene, but we’re looking at masks, not drugs. We [had] become pretty good at spotting counterfeits, and a lot of stuff being pushed out there was counterfeit or straight surgical masks.”

Mr. Vazquez was able to find a reputable vendor though a local pharmacist, but his troubles did not end there. The vendor gave him 24 hours to come up with the funding – which was eventually paid for through the county society’s reserve fund. And Mr. Vasquez had to find partners willing to buy enough PPE to make the deal worthwhile to the vendor.

In that 24-hour period, major partners dropped out of the original transaction for 50,000 N95 masks, and it looked like the deal might fall through. Finally, Mr. Vasquez got local emergency medical services and the City of Brownsville to commit to taking a share, pushing the order close to 20,000 masks – enough for the vendor to go through with it.

Wary of being scammed, Mr. Vasquez demanded video of the vendor opening boxes with the masks and taking them out to prove their authenticity. And when they were ready to be shipped, he rented a trailer and drove to Austin to pick them up from the supplier.

Opening the boxes to check their contents was an emotional experience.

“I’ve got to tell you, I cried,” he said. “It was just the anxiety of wanting to deliver for our doctors and knowing all that was riding on these masks.” Physicians routinely reused masks – a previously unusual practice – and the Texas Medical Association has worked closely with the Texas State Operations Center to secure PPE for community physicians. Also, many county societies have held drives to solicit PPE contributions from their communities.

The shortage was made worse by federal intervention. The U.S. Federal Emergency Management Agency at one point had been quietly seizing PPE orders, though it was not clear what the agency was doing with them, according to the Los Angeles Times. In early April, staff from the Department of Health and Human Services told the U.S. House Oversight and Reform Committee that PPE in the Strategic National Stockpile was nearly gone, and states could expect no more shipments, The Hill reported.

On the private market, prices for medical supplies – especially N95 masks – had soared, Mr. Vazquez said. A mask that typically cost $1 in 2019 could cost up to $9, he said.

Not all Texas county societies had as much trouble obtaining PPE as Mr. Vasquez. For instance, the Collin-Fannin County Medical Society in North Texas was able to obtain consistent shipments of PPE through suppliers in the U.S. and China, said Sam Barbee, the society’s executive director.

However, it paid a “premium price” of about $4.50 per N95 mask for about 10,000 masks, and nothing about the procurement process was normal.

“I feel like I work at Chick-fil-A,” he said. “We order a product, it comes on a truck, and we distribute it in parking lots, and people are driving up and taking their orders through their window.”

The Collin-Fannin County Medical Society also found local companies that retooled their production in ways that help. For instance, the Garland leather cutting company Cut Form changed its production process to create useful medical face shields, Mr. Barbee said.

Obtaining reputable equipment was mostly a matter of making good contacts and watching out for rip-off artists, he said.

“You’ve got to talk to them and get follow up, and you’ve got to get referrals,” he said. “And if those don’t pan out – and they won’t [if they’re fraudulent] – you know it’s a dead deal.”

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County Medical Societies Take A Bite Out of PPE Shortfall

For the medical community, the early days of the COVID-19 pandemic were defined by shortages: testing shortages, ventilator shortages, and personal protective equipment (PPE) shortages.

While the Texas Medical Association and other health care organizations advocated hard to reverse these shortages in Texas, more than 12 county medical societies along with the Texas College of Emergency Physicians and several alliance chapters found a temporary workaround for the PPE famine: They asked their communities to donate masks, gloves, face shields, or any other medical supplies that protect them from infection.

And Texans responded.

“It’s been really unbelievably humbling to see how the community has come together to help us,” said Sapna Singh, MD, a Sugar Land pediatrician and past president of the Fort Bend County Medical Society. “That’s perhaps the one silver lining [to the pandemic] – that patients, doctors, nurses are all seeing how much we matter to one another.”

The Fort Bend society collected more than 500 masks and other PPE, and like many other county societies, got the PPE first to front-line physicians – in local hospitals and primary care practices.

Major companies and organizations stepped up to contribute, but they tended to be in larger cities like Houston, Dr. Singh said. In Fort Bend, which lies near the Gulf Coast, most of the contributions came from ordinary people and small businesses. Many residents owned unused N95 masks and other medical equipment acquired during the cleanup from Hurricane Harvey in 2017, she said.

“People just started dropping off leftover masks,” Dr. Singh said. “They were like, ‘I’ve got 20 in my garage – I’ve got a whole box I never opened,’ or a whole bunch of gloves they never used.”

In Lubbock County, the county medical society, alliance, and medical students promoted their PPE campaign via Facebook and by contacting local businesses. The outpouring was tremendous, said Ashley Sturgeon, MD, a dermatologist and president of the Lubbock County Medical Society. Agricultural companies, construction firms, nail salons, and dentists stepped up with contributions.

That allowed the society to distribute 1,512 masks to hospitals and 1,822 to local physicians. It also distributed hundreds of gowns, hats, shoe covers, boxes of gloves, and alcohol wipes, she said.

This clearly saved lives, but it also helped ease the stress all physicians were feeling, Dr. Sturgeon said.

“We’re all on edge right now and are waiting for the other shoe to drop here in Lubbock,” she said. “Doctors are afraid, and they’re afraid for their families and what they’ll be bringing home. I think having just one mask that they knew they could have if they really needed it helped a lot of people sleep at night.”

Many of the physicians say they were largely sidelined at least in part because of the PPE shortage. Those physicians provide elective procedures or services that were mostly halted so that valuable PPE could be diverted to front-line physicians and medical staff.

That was the case for Mark Glover, MD, the Austin surgeon who kicked off the Travis County Medical Society’s effort. He saw his patient load dwindle as a result of the governor’s order to suspend non-urgent elective procedures.

“About 80% to 90% of what I do is elective surgery [mostly on hernias],” he said. “That’s why I’m the perfect person to take this. Me and my [business] partner still take emergency calls, still do operations, still see patients, but per the American College of Surgeons guidelines … we’re really trying to limit the people going into the operating room if at all possible.”

The Travis County drive started accidentally when one of Dr. Glover’s neighbors pointed out that he had five N95 masks he was willing to donate.

“And I wondered who else might have N95 masks lying around that they’re not using,” he said.

Dr. Glover put a notice on neighborhood websites and social media asking for more donations. To his surprise, they flooded in. Travis County Medical Society became the distribution point for the 1,300 N95 masks that were contributed as well as 5,000 masks received from the Strategic National Stockpile, a national repository of medical supplies run by the U.S. government.

The society “has become a hub,” he said. “We take requests and then disperse them out.”

In all, Travis County’s society received more than 70,000 pieces of PPE, and the sources had been diverse. Tito’s Vodka donated hand sanitizer. The Amazon TV series Panic donated boxes of unused PPE left over from the show’s morgue scenes. Local obstetrician-gynecologist practices donated swab kits for COVID-19 testing.

While Dr. Glover is grateful for the community’s generosity, he’s aware that a PPE drive is a temporary solution to a much bigger problem.

“This is just a Band-Aid on what everybody really needs,” he said.

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TTUHSC’s Mask Decontamination Project

The international shortage of N95 masks forced Texas physicians to reuse existing masks – a desperation tactic with an obvious drawback: Used masks are unsanitary.

Some hospitals and health care institutions had decontamination chambers to sterilize the used masks, but the Texas Tech University Health Sciences Center (TTUHSC) in Lubbock created a chamber that could decontaminate 10,000 masks at a time. The center offered to do it for free for any Texas physician or medical entity that needed it.

The TTUHSC project was available to medical institutions of any size, said Min Kang, interim senior vice president for research. She is head of the decontamination project and a pharmacist.

“But the organizations that really, really need help [with reusing masks] are small private practitioners, hospitals, and health care organizations because they can’t get the N95 masks, and they don’t have the resources to send them out for decontamination,” she said.

The Lubbock County Medical Society promoted the project – and a local dropoff site – to all of its members, said Executive Director Juanema Christensen.

Lubbock’s University Medical Center (UMC) was one of the first customers, said Jacob Nichols, MD, the hospital’s medical director for infection prevention and control. UMC has limited decontamination facilities that can sterilize small batches of masks, but the TTUHSC facility could make thousands more masks ready to use.

“We do have some [masks] available, but we know we haven’t reached our peak number of patients yet [in the pandemic], so we’re wanting to conserve the things that we have right now so that moving forward we still have some supplies,” Dr. Nichols said.

UMC and eight other institutions had masks sterilized in the TTUHSC unit’s first run, Ms. Kang said. The unit, located at The Institute of Environmental and Human Health in Lubbock, decontaminates using a device that vaporizes hydrogen peroxide.

The masks are arranged on wire shelves, exposed to the vapor for 15 minutes, and then allowed to aerate for four to five hours. Eight bioindicator cards containing hard-to-kill bacteria are put in with the masks to show the decontamination is complete, she explains.

The U.S. Centers for Disease Control and Prevention offers guidelines on decontaminating masks, as well as precautions health care professionals should follow when using decontaminated masks. The Texas Department of State Health Services says that decontamination should be viewed “only as a crisis capacity strategy.”

“I’m hoping this will alleviate the problems so that at some point the supply chain will be restored,” Dr. Nichols said.

Masks can be safely decontaminated two or three times, according to a U.S. government study. But they tend to fall apart quickly after steady use, Dr. Nichols said.

“Studies have shown that the masks can be safely decontaminated and retain their filtration efficacy,” he said. “The main issue is that after several cycles, the straps start to break down, and if you don’t have the straps, the mask is essentially nonfunctional.”

The Food and Drug Administration gave emergency approval to the hydrogen peroxide decontamination method in March so that masks and other personal protective equipment (PPE) could be sterilized and reused, Ms. Kang said. The approval was just for Battelle, an Ohio nonprofit, but other organizations and companies used it as well, she said.

The equipment for the process can be found only at facilities with a rating of biosafety level 3 or 4, the labs equipped to study the most dangerous types of pathogens, Ms. Kang added.

While TTUHSC decontaminated masks and PPE like face shields without cost, the medical practices or health care institutions that sent masks were responsible for transporting the items to the Lubbock facility, she said. U.S. Department of Transportation rules require that used masks and contaminated PPE must be put in biohazard bags that are then put in biohazard containers before being shipped.

Tex Med. 2020;116(6):22-26
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Last Updated On

June 26, 2020

Sean Price

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(512) 370-1392

Sean Price is a reporter for Texas Medicine and Texas Medicine Today. He grew up in Fort Worth and graduated from the University of Texas at Austin. He's worked as an award-winning writer and editor for a variety of national magazine, book, and website publishers in New York and Washington. He's also helped produce Texas-based marketing campaigns designed to promote public health. Sean lives in Austin and enjoys hiking, photography, and spending time with his wife and two sons.

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