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Editorial
March 20, 2020

Conserving Supply of Personal Protective Equipment—A Call for Ideas

Author Affiliations
  • 1Dr Bauchner is Editor in Chief, Dr Fontanarosa is Executive Editor, and Dr Livingston is Deputy Editor, JAMA
JAMA. 2020;323(19):1911. doi:10.1001/jama.2020.4770

The editors of JAMA recognize the challenges, concerns, and frustration about the shortage of personal protective equipment (PPE) that is affecting the care of patients and safety of health care workers in the US and around the world. We seek creative immediate solutions for how to maximize the use of PPE, to conserve the supply of PPE, and to identify new sources of PPE. We are interested in suggestions, recommendations, and potential actions from individuals who have relevant experience, especially from physicians, other health care professionals, and administrators in hospitals and other clinical settings. JAMA is inviting immediate suggestions, which can be added as online comments to this article.

Note: The online version displays comments from the initial publication. It is now closed to new comments and suggestions.

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Article Information

Corresponding Author: Howard Bauchner, MD (howard.bauchner@jamanetwork.org).

Published Online: March 20, 2020. doi:10.1001/jama.2020.4770

Conflict of Interest Disclosures: None reported.

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    291 Comments for this article
    EXPAND ALL
    PPE supplies Through International Collaboration
    Ziheng Xu, Medical Student | Washington University School of Medicine
    The usage side of the equation matters. But as an international student whose family and loved ones have just gone through arguably the worse phase of the outbreak, I cannot stop but thinking about ways my home country could contribute. The collaboration and ties between the two countries run deeper, especially in trying times like this.

    Some of my colleagues and I have been organizing at our school a small supply drive from our family and friends at home to our University hospital. But I have been wondering if a coordinated effort can be taken leveraging the presence
    of international students at major US academic institutions.

    Given China's slow but promising recovery from the pandemic, and more importantly, the power of manufacturing and production, I am hopeful that in ways big or small, contributions can be made in order to address the dire shortage of PPE in US hospitals. To take it one step further, official collaborations between US and Chinese institutions could also be made to set up direct supply support. I am more than happy to help in coordinating such an effort, and I hope this could also serve as an inspiration in other institutions home or abroad alike.
    CONFLICT OF INTEREST: None Reported
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    Why are Ambulatory Surgical Centers Still Doing Elective Surgeries?
    Ronald Hirsch, MD | Regulatory Expert
    Elective surgeries are still ongoing at ambulatory surgical centers (ASCs). Physician owners are placing their own financial benefit ahead of all else. There should be no cosmetic surgeries, no cataract extractions, no joint replacements, and no screening colonoscopies,
    CONFLICT OF INTEREST: None Reported
    Supplied Air Systems for PAPR sparing
    John Pearson, MD | University of Utah School of Medicine
    There is a great deal of focus on PAPR and concern about the limited supply of the air purifying unit. However the protective feature is the positive air flow, and using non-contaminated air for that flow. The headpiece itself may or may not be in short supply, though that is able to be custom-made or production can be ramped up easily.

    The solution then is to use widely available air supply lines found in many ICUs and Operating Rooms. This supply is typically at 55 l/min and with a pressure regulator and splitter can be piped to several
    care team members. This is already in use in industry and available from 3M (1) and others though it can be custom-made too. This would allow for mobile PAPR units to be used in cases of need and stationary care to be provided by supply air systems. We are actively investigating this at the University of Utah.

    References
    1. https://www.3m.com/3M/en_US/company-us/all-3m-products/?N=5002385+8709322+8711017+8711405+8720539+8720547+8720781+3294857497&rt=r3
    CONFLICT OF INTEREST: CEO and Founder of SPRYTHM LLC, a medical smartphone app company focused on respiratory care.
    READ MORE
    Snorkel Masks as Protective
    Anh L Tran, BSN | Brigham and Women's Hospital
    Snorkel masks could serve as a reusable and waterproof protective gear for eyes, nose, and mouth. It allows the healthcare worker to breath comfortably and avoid any droplet contamination on their face. It can also be easily wiped and cleaned with a disinfectant to be reused. Each healthcare worker will only need to own one snorkel mask.
    CONFLICT OF INTEREST: None Reported
    Buy Back PPE
    Anjali Bhatla, Medical Student | Perelman School of Medicine at the University of Pennsylvania
    The increase in media attention on COVID-19 in the weeks leading up to the coronavirus outbreak in the United States led to reports of sold out face masks, hand sanitizers, and other cleaning products in stores. While it is understandable that this situation is unnerving, we have now reached a critical juncture where healthcare workers that are putting themselves on the line do not have enough protective equipment for themselves. While efforts around rationing and reusing equipment are already underway at many hospitals, it is critical to increase supply as experts expect this crisis to last for many more weeks to months.

    Manufacturing more masks is certainly needed, but is definitely not an immediate process. I propose that either the federal government or local/state officials in places most affected try to buy back PPE that was previously bought by community members. Hopefully as individuals see healthcare workers around them risking their lives, they will be willing to give some of their personal stock of equipment up for the betterment of those being affected by COVID 19. This could provide some stock of equipment that can serve as a temporary relief as more long-term solutions are proposed.
    CONFLICT OF INTEREST: None Reported
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    UV Light Machines For Decontamination
    Vicky Cerino, BS | University of Nebraska Medical Center
    In light of the national shortage of one-use personal protective equipment (PPE), the University of Nebraska Medical Center and its hospital partner, Nebraska Medicine, have developed a safe and effective method to decontaminate these items so they can be used multiple times instead of just once.

    A team led by John Lowe, PhD, UNMC assistant vice chancellor for inter-professional health security training and education, is using ultraviolet light towers to irradiate high numbers of masks, which were originally designed to only be used once. The strategy will allow Nebraska Medicine to greatly extend its supply of these items during
    the coronavirus pandemic.

    “The shortage of PPE is a nationwide issue – each and every one of these items is increasingly precious,” said Mark Rupp, MD, chief of the infectious diseases division at UNMC. “Although we were well prepared, our supplies were beginning to dwindle. We had to find a way to keep our providers and patients safe, and this will definitely help us achieve that goal.”

    The decontamination of these items works like this: groups of masks are safely bagged and transported to a room inside the hospital which is equipped with two ultraviolet light towers. The PPE is hung on wires stretching the length of the room and then decontaminated when the lights are powered on. The items are then removed and returned to the original owners for reuse.

    “The shortage has forced us to be innovative,” said Dr. Lowe. “While these items weren’t meant to be used more than once, this is a 100% safe way to extend their useful life. Other major hospital systems in the U.S. have also started to implement this method for the same reason we are.”

    Our staff members have been provided with instructions on how to safely remove their PPE and place it in bags for transport to the decontamination room.

    Several community partners and concerned members of the public have offered to donate masks to help us in this time of need. We greatly appreciate these offers and are exploring all of them to continue to add to our stockpile of personal protective equipment.
    CONFLICT OF INTEREST: None Reported
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    Snorkel Masks Modified With 3D printing
    Fabricio Webber, MD |
    Developing Ms Anh Tran's idea, combine “full face” diving masks (the sort that became popular recently) with 3D printing to adapt the snorkel area with a p100 filter, using 1 instead of the usual 2 filters. These have a good sealing and should be relatively low cost; the filter should be good enough for 1 month, and the mask should be easy to clean.
    CONFLICT OF INTEREST: None Reported
    Organize homesewn PPE drives and homemade bandanas
    Paul Bergl, M.D. | Medical College of Wisconsin
    I have been amazed at the response in our medical school, my church, and my community when I put out a call this morning to start making homemade PPE. We are now collecting homemade bandanas (from old T-shirts, which we all have sitting in our closets and dressers), and we are asking community members to begin sewing reusable, washable masks.

    There are multiple ways these can be made; an example is here:

    https://www.deaconess.com/SpecialPages/How-to-make-a-Face-Mask

    There is a literally an army of citizens waiting to help. If the CDC is endorsing this approach, let's mobilize all of
    the extra cotton in our dressers and all of the help in our communities.
    CONFLICT OF INTEREST: None Reported
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    Re-usable Respirators
    Cameron Smith, MD, PhD | University of Florida, Department of Anesthesiology
    Several manufacturers, including 3M and Honeywell produce reusable respirators in both full-face (covers eyes as well as nose/mouth) and half-face (just nose/mouth) variations. These accept changeable filtre cartridges which can be used for much more than a single use if stored properly.

    Another option would be to investigate the potential utility of SCUBA equipment. While open-circuit equipment is likely to heavy to wear for extended periods, surface-supplied SCUBA equipment could be connected to wall gas supplies. Using them in combination with full face diving masks would protect the entire face, supply breathing gas from a source completely isolated
    from potentially contaminated ambient air, and would be re-usable.
    CONFLICT OF INTEREST: None Reported
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    Leverage telehealth, 3D laser print-assisted PPE supply chain
    Sophia Boettcher, BS CS | Melinda A. Costa, M.D.; Life Plus Pharmacy; Armadyllo QData Commons
    Swedish/St. Joseph’s Providence is making homemade PPE. They worked with the ID specialist to prototype one and are putting them to work now:

    https://komonews.com/news/coronavirus/volunteers-making-homemade-equipment-to-combat-shortages-caused-by-covid-19

    This has been done also in Belgium (the nonprofit worked with government to design templates):

    https://maakjemondmasker.be/

    There’s more research in mask solutions in a pinch:

    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3373043/

    We need to cut down on all unnecessary use of PPE and reallocate to hospitals treating active COVID-19 patients.

    In addition we should enable every able-bodied individual who can sew to produce masks locally. There is a lot of data on the benefits
    of crowdsourcing and having a local pipeline in case international ones are disrupted is vital.

    We could work with 3D laser print companies like Glowforge or computerized sewing machines to design a 3D-laser assisted working prototype. These prototypes could be washed/ disinfected daily and we could swap out 2.5ppm inserts after use (up to N95 equivalent protection) and when it’s not possible to get inserts, at least they’d have somewhat comparable protection to surgical masks.

    If anyone wants to help me, my email is sophia@armadyllo.org. We are trying to launch this emergency charitable endeavor right now.
    CONFLICT OF INTEREST: None Reported
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    Safety Face Shields - 3D printed Headgear with PETE Shield from Water Bottles
    Frank Fedel, PhD (ABD) | Eastern Michigan University
    Not necessarily an immediate solution, but companies that make PETE water bottles could use their blow-molding capabilities to make larger diameter, clear plastic bottles that could be cut into curved pieces for face shields, and 3D printing could be used to make the headgear components. UV sterilization? Someone might be able to build on this idea.
    CONFLICT OF INTEREST: None Reported
    Conserve usage where appropriate
    Zhe Yu, MD | Oliver Wyman
    Where appropriate, in common non-droplet precaution areas, allow one mask per clinician per day, or q4h / q6h.

    Workflow-wise, for each droplet room visit, still change the whole set of PPE, but once the clinician exits, after doffing and hand washing. change to the common area mask which gets changed less frequently.
    CONFLICT OF INTEREST: None Reported
    Use of Technology
    Monali Vasekar, MD | Penn State Health
    An easy, implementable and readily available resource could be to use Smart Technology such as drones and robots to administer tests to patients suspected of having COVID19. For example, a video-enabled drone could deliver testing kits while the patient waits in their vehicle. They perform self testing and load the kit onto the drone while a healthcare worker watches them via video to ensure adequate testing.

    Drones and robots could also be assigned tasks such as checking temperatures and taking vital signs , delivering medications and many such tasks; while they are placed in video-enabled rooms under direct
    observation of nursing staff. Of course this equipment should be sanitized between each visit. This practice may help decrease direct exposure of healthcare workers and conserve precious PPE.
    CONFLICT OF INTEREST: None Reported
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    New sources of PPE
    Erafat Rehim, MD | LVHN
    As Xu mentioned above/below, China went through the worst phase of the pandemic. Chinese-American communities across the nation are orchestrating the supply of PPE from China to the states, and this was made possible by a relative surge of PPE production in China.

    The transportation of the supplies can be expedited by initiating communication directly between states and provinces in China, and/or between institutions, i.e. on the government level.

    Some US institutions have established academic collaborations with Chinese institutions and have shared academic activities including exchange students and research collaborations; this may be a good time to
    further the collaboration by giving each other a hand.

    I am happy to help.
    CONFLICT OF INTEREST: None Reported
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    MacGyver Some PPE
    Danielle Jackson, MD MPh |
    Many industries outside of medicine have stock of at least particulate filtering masks, including painters, construction companies, Rail Workers (Amtrak) and ALL city transit. An immediate solution would be for those cities' mass transit to call for a mandatory donation of a portion of those masks to hospitals in their municipality reporting the greatest shortages.

    Also, any noncombustible fabric that can be autoclaved (think surgical drapes) can provide an external barrier and its sterility rapidly tested with autoclave testing strips. The issue is comfort/ease of wear for the MD. Adding 100% cotton fabric as the inner layers
    with the outer layer composed of wetlaid paper drape could be an option.

    Reference

    https://animalhospitalsupply.com/better-vet-surgical-materials/
    CONFLICT OF INTEREST: None Reported
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    Have The American Dental Association Encourage Possible PPE Donations By Dentists
    Austin Ritter, Medical Student | Lake Erie College of Osteopathic Medicine
    My father is a Dentist in Maryland. In line with ADA guidance, he has closed his practice for all but significant dental emergencies.

    He estimates he has about 1000 surgical masks in stock (about 2 weeks worth). According to my research there are about 2,500 dental practices in Maryland.

    2500 practices * 1000 masks/practice = 2.5 million masks, of which a large portion may no longer be needed due to dentists cancelling elective appointments.

    The American Dental Association could send out an immediate communication advising on best practices for donating PPE.
    CONFLICT OF INTEREST: None Reported
    Ultraviolet Germicidal Irradiation to Reuse Otherwise Disposable PPE
    Charles Sanky, BA | Icahn School of Medicine at Mount Sinai
    We propose decontamination of PPE using UV germicidal irradiation (UVGI) exposure so masks can be safely reused. This technology has been efficacious in sterilizing masks for reuse following influenza and H5N1 infection in numerous studies. This method will fill the gap to protect healthcare workers until production of new, disposable PPE can be adequately increased to meet demand. Our proposal addresses >4 log10 reductions in viral titer levels, maintenance of post-decontamination performance of equipment, and cost and safety of implementation of UV Germicidal Irradiation technology.

    We are developing two models of implementation that could prove cost effective with minimal
    disruption of current workflow. Implementation would likely vary based on health system but would effectively conserve PPE. A formal proposal with technical specifications and cost-benefit analysis will be submitted for peer-review and dissemination.

    Charles Sanky, MD-MPH Candidate, Icahn School of Medicine at Mount Sinai
    Estefania Chavez, MD Candidate, Columbia University Vagelos College of Physicians & Surgeons
    Jason Williams, PhD Candidate in Physics & Astronomy, University of Southern California
    Ajit Singh, MD Candidate, University of Pittsburgh School of Medicine
    Megan Ramond, MD Candidate, University of Pittsburgh School of Medicine
    Matthew Sheridan, BS Mechanical Engineering, Columbia University School of Engineering
    CONFLICT OF INTEREST: None Reported
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    Call on Colleagues in Dentistry and Veterinary Medicine To Donate PPE
    Carol Bunten, MD | Vancouver Clinic
    Many other industries use PPE for very elective things. In this time of crisis, and through advertising and direct appeal, I'm sure we could get supplies of masks, gowns, and gloves from colleagues in dentistry, veterinary medicine, even the spa industry. Publicizing on news outlets and publishing a list of hospital contacts to direct donations towards could provide a boost when we need it most.
    CONFLICT OF INTEREST: None Reported
    Repetitive use of surgical masks with cloth sleeves
    Tzu-Hao Lee, MD | Duke University Medical Center
    As U.S. physicians who also received medical training in Taiwan, we would like to share a concept of using the surgical mask sleeve, which is commonly used by large numbers of people of Taiwan in the COVID-19 pandemic due to shortage of PPE.

    In Asian countries, wearing masks when individuals have viral illnesses or during a viral outbreak is very popular, especially after the SARS outbreak in 2003. During the COVID-19 outbreak, due to a shortage of PPE, people have developed creative ways to manage to repetitively use PPE. Surgical masks sleeves are among the most commonly used
    and widely accepted methods. The sleeve is a packet made of soft cloth to cover the whole mask. The greatest advantage of the sleeves is that it can be repetitively cleaned in a thorough and disinfected way, such as using the detergent and hot boiled water. In addition, it can provide the air seal almost as ideal as the surgical masks. By wearing a sleeve that contains the surgical mask, the mask thus could be repetitively used. The material (i.e., cloth) is easily accessible and affordable to the general public and can be made in different colors for outer vs. inner lining to avoid contamination when fetching the sleeves.

    We think it's a brilliant way to use mask sleeves. We will submit a brief letter with more details to be shared with the healthcare professionals and the general public.

    Tzu-Hao (Howard) Lee, MD, Duke University Medical Center
    Chi-Ying (Roy) Lin, MD MPH, Columbia University Medical Center
    CONFLICT OF INTEREST: None Reported
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    Disinfection Processes Need to be Better Studied.
    Katrina Hui, MD, MS | University of Toronto
    As some others have mentioned, we may have to look more closely at disinfection of PPE. There are some studies, as already pointed out by other commenters, that demonstrate reusable elastomeric respirators that can be effectively disinfected and reused, especially if done in a systematized way. For example, Bessessen et al. tested several models with a standard operating procedure for disinfection (1). 

    I think we need to better study disinfection with bleach, UV, etc. on disposable PPE as well to see if it affects integrity of the protective structure or allows us to reuse them at least several times. />
    Reference

    1. https://www.sciencedirect.com/science/article/pii/S0196655315000899.
    CONFLICT OF INTEREST: None Reported
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    Maximize Telemedicine Technology
    David Padalino, MD | Crouse Hospital, Private Practice, Syracuse, NY
    We have all been trained to put hands on all patients. It’s a fundamental part of our training. We have also seen unnecessary entering and exiting of isolation rooms that increase exposures to staff and other patients. With the era of telemedicine and access to devices that allow us to put digital eyes and ears on our patients, we can maximize this technology to have dedicated monitoring stations to keep our patients safe and reduce the risk of contamination in isolation cases, thereby reducing wasteful misuse of critical PPE equipment that is in terribly short supply. Of course, if the patient needs hands-on care, it is deemed necessary and done properly. Patients who ring the call bell to ask a question can have the question answered without the staff entering the room at all since they can be available electronically at all times even if from a nursing station just outside of the patient’s room. This would effectively reduce the waste of precious supplies and conserve them for the necessary patient care that does require hands to be laid on the patient, with proper protection. Automated BP, heart rate, SpO2 are already widely available, and adding devices with cameras and microphones can add a layer of safety with continuous monitoring and limit unnecessary exposures and waste of precious resources.
    CONFLICT OF INTEREST: None Reported
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    Gas masks?
    Noah Grysman, MD | Resident Physician, Psychiatry
    Would gas masks previously given to military, law enforcement, and civilians in foreign countries during threat of biological warfare (eg Israeli civilian 4A1 gas masks) have efficacy for prevention, and for how long? While its efficacy against biological warfare is only for up to an hour, would it be longer for something like droplet precautions?
    CONFLICT OF INTEREST: None Reported
    Shorten Procurement Through Transparency with Suppliers for Just-In-Time procurement.
    Iqbal Shariff, MBA Healthcare Management | Home Healthcare CEO
    Our team is transparent with suppliers about our needs, and we help forecast the suppliers' revenues. Our team also connects acuity of care with appropriate PPE. With the pandemic, we have connected the acuity of care, utilization of supplies, with procurement with suppliers. This makes rationing more easier.

    We can also borrow from dentist offices, the construction industry, painters, and manufacturing. They utilize the same PPE as healthcare does.
    CONFLICT OF INTEREST: None Reported
    DIY Solutions That Are Easy to Reuse/Relaunder
    David Gee, MD |
    There's old data indicating that the material used in masks matters less than the fit (1).  Pick and widely publicize a design that ID specialists are happy with, employ the community to make lots, and put masks on both providers and patients. The Koreans have also developed DIY solutions, so it's probably not necessary to reinvent the wheel. 

    References

    1. Br J Surg. 1975 Dec;62(12):936-40. The efficiency of surgical masks of varying design and composition. Quesnel LB.

    2. https://m.blog.naver.com/hohuk212/221838542113
    CONFLICT OF INTEREST: None Reported
    Decontamination
    Michael Gilson, MD PhD | UC San Diego
    A technical expert at 3M warned me that decontamination measures, such as UV, vaporized hydrogen peroxide (refs below), might weaken the elastic straps so the mask would not make a tight enough seal. Also, the filter material has a permanent static charge to help trap particles, and this might not withstand treatment. Thus, any decontamination method will have to be well tested. Authoritative input on this would be welcome.

    Perhaps worth mentioning: on any surface, the virus dies off over time anyhow, so merely storing used masks for a week might adequately decontaminate them. Not sure
    about other pathogens.

    http://wayback.archive-it.org/7993/20170113034232/http://www.fda.gov/downloads/EmergencyPreparedness/Counterterrorism/MedicalCountermeasures/MCMRegulatoryScience/UCM516998.pdf
    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2781738/
    CONFLICT OF INTEREST: None Reported
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    Teleconsults
    Matthew Way |
    A measure that will limit unnecessary exposure of staff both in and out of the hospital and thereby limit the use of PPE that is available immediately is the use of telemedicine services such as doxy.me.

    There are likely other services available, but this one is functional and requires no end user "app" to install, making it especially easy for patients to use on nearly every media capable device.

    Since the government has waived the usual HIPAA requirements for telemedicine, in this crisis it is imperative to maximize our resources and this is one measure that
    can be immediately implemented by hospital systems.
    CONFLICT OF INTEREST: None Reported
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    Make Nursing Home PPE Optional
    Mary Braun, MD | Lamprey Health Care
    Some nursing home patients with special circumstances - those at end of life or with dementia with behaviors -  are allowed visitors at nursing homes but the visitor is asked to use a full set of PPE for each visit even though they have no symptoms because that is the CMS rule. Allowing the use of PPE at the discretion of the nursing home door screener would save a full set per day per visitor. Not a huge savings, but an easy step to take.
    CONFLICT OF INTEREST: None Reported
    Why not do it the same way it was originally done?
    Michael Williams, BA Econ, Brown | I'm a dev
    The solution is simple: put unsoiled N95 masks in a box, drive them to an ethylene oxide (EtO) sterilizer overnight, and 12 hours later, the mask is like. EtO sterilization has been used for years with bandages and the like. Sample techniques to limit reuse to a number of cycles could include marking the date of use on the mask with a felt tip pen, for example, and adding a mark for each day.

    The technique is already well documented in the literature (1).

    There is some supply of new and used EtO sterilizers on the market,
    and there may be one in your community. Regional synergy could be achieved. I don't understand why hospitals haven't jumped on this.

    Two other options:

    1. Dragoon people who have recovered from COVID-19 into service as biorobots for telemedicine. Taking vital signs and initial patient encounters all can be taught relatively rapidly, especially if under continuous medical supervision.

    2. Seek comparable sources of PPE. Half-face construction respirators are obvious, and can be found eg on agricultural and industrial sites still in some stock, but consider also welding respirators. They generally have HEPA filters and are designed to provide continuous positive pressure. Again, truly shocked these haven't been all picked up by now. See the PAPR-Welding helmet combination video (2) eg for a sense of what I'm talking about.

    REFERENCE

    1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2781738/
    2. https://www.youtube.com/watch?v=zyIRpS3ZdQ4
    CONFLICT OF INTEREST: None Reported
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    Supply Management of PPE
    Prof Gunachandran, M.Sc | Professor in Forensic Science and Chemical Examiner in the State of Tamil Nadu India
    It it common for people to panic in reaction to an epidemic outbreak and become more selfish to protect themselves and their loved ones from a possible infection. When PPEs like gloves or masks are available over the counter, such panic buying can not be restricted.

    However if the equipment were packaged in fewer numbers -  for example 5 or 10 instead of 50 or 100 or more -- more stock would be available for others. Bulk packages with 100 or 200 should be supplied only to institutional purchasers and not to individuals.

    Also, masks that filter
    lessor smaller (micron) particles should be supplied only to health Institutions and needy elderly or ailing people who may be more susceptible to such infection, either on prescription or on establishing their identity.

    This may help align supply toward a more fair and equitable distribution, especially perhaps for masks which is not a restricted item at present.
    CONFLICT OF INTEREST: None Reported
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    Scarcity of Personal Protective Equipment for COVID-19: Food rationing as a relevant analogue
    Stephen Levick, M.D. | University of Pennsylvania School of Medicine
    Historically, vital resources have been rationed by governmental bodies when scarce. Perhaps food shortages represent the best analogue to the current shortage of Personal Protective Equipment (PPE), in the context of the COVID-19 pandemic.

    With a shared sense of purpose in fighting a common enemy, as with food rationing in the United States in 1942, even an unsophisticated system of allocation was fairly successful. Individuals and families got the food they needed, and hoarding was reduced.

    Though many of us are relatively isolated by social distancing directives, all of us, but especially physicians, can convey
    a shared sense of purpose now: the virus is the enemy to be fought, and we must protect not only ourselves, but those among us most vulnerable to it. In contrast, an adversarial view of certain other countries or people is most unhelpful.

    A governmental PPE rationing body must be fair and just, and able to nimbly respond to a rapidly evolving situation. Scientific knowledge of COVID-19, the prospect of safe and effective treatments, and a vaccine proceed apace. A scientific advisory board should include biologists, physicians, manufacturers and merchants of PPE’s. Psychological, social, and economic scientists can help us to better understand and craft policies and messages that mitigate individual and societal fears that fuel PPE hoarding.

    The varied outcomes of food rationing practices give us food for thought on this vital issue.
    CONFLICT OF INTEREST: None Reported
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    Snorkel Masks in the COVID-19 era
    John Healey, MD | Memorial Sloan Kettering Cancer Center
    Personalized medicine for providers should be a priority, even while providing care in a pandemic.

    Well-fitting snorkel masks are a brilliant suggestion. They raise and narrow the air intake funnel by 1 Ft, reduce droplet presentation, diminish aerosol exposure, and prevent facial touching and viral transport. Better provider and patient protection will come from this simple form of personalized medicine.
    CONFLICT OF INTEREST: None Reported
    Risk Stratify & Reuse, Recreate, Robots
    Wan Yee Kong, MD | Detroit Medical Centre, Wayne State University
    Risk Stratify:

    Systematically categorize patients into

    - Definite COVID-19 (positive cases)
    - High probability COVID-19 (pending test, suggestive symptoms and definite contact)
    - Moderate probability COVID-19 (pending test, suggestive symptoms and no known contact; low probability (pending test, suggestive symptoms but has other differentials explaining respiratory symptoms)

    Group these patients together according to their risk, physician/ health care providers can use one set of PPE while treating the same group of patients. This allows conservation of PPE while minimizing risk of transmission of COVID-19 to patients of a different risk category.

    Lastly, if COVID-19
    surges exceed >50% of the population; isolating healthy patients with designated treating healthcare workers without PPE, and the rest of healthcare workers donning 1 set of PPE / day for all other patients, may be a consideration.

    Recreate

    An oversized clear plastic bag covering the face with a respirator N95 mask underneath, secured by gown by tucking the plastic underneath gown at the front leaving a gap behind to allow ventilation, might recreate current protection. Plastic bags can be purchased in rolls (similar to those in supermarket) and placed outside patient’s room. This also allows safer reuse of the mask as it is protected by bag.

    Robots

    Robots

    Both commercial and hospital robots can be utilised to continue providing patient care. TUG delivery robots which have been used for medicine deliver can be used to deliver food/medicine/supplies into patients' rooms. Telepresence robots can be utilized for interviewing patients without close contact.
    CONFLICT OF INTEREST: None Reported
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    Make Your Own Reusable Respirator During the N95 Shortage
    Farokh Demehri, MD | Boston Children's Hospital
    During this critical shortage of N95 respirators, we have been working on a method to create your own reusable respirator using only a face mask, an in-line ventilator filter, and two elastic straps. All for less than 3 dollars! Find instructions, details, and video at childrenshospital.org/surginnovation
    CONFLICT OF INTEREST: None Reported
    Repurposing disposed of materials
    Nicholas Hackett, MD | Northwestern University Feinberg School of Medicine
    I think one solution is using materials that can be re-sterilized. Cloth masks and cloth aprons that can be put through an autoclave, for example.

    To be even more thrifty we could use materials that are often discarded in ORs. For example, sterile blue towels that are often thrown away could be used to cover faces (attached via tying with string eg). These could of course be re-sterilized in an autoclave.

    Gloves could also be re-used if washed while the person is wearing them, eg with alcohol hand sanitizer while still wearing the gloves.
    CONFLICT OF INTEREST: None Reported
    Start Planning for Regionalization of COVID-19 Care NOW
    Elizabeth Pathak, MSPH, PhD | Women's Institute for Independent Social Enquiry www.wiise-usa.org
    In the USA, localities that have not yet experienced a surge of COVID-19 patients should start planning immediately for implementing regionalized COVID-19 care. A regional task force could be comprised of representatives of hospitals, outpatient practices (including pediatricians), nursing homes and long-term care facilities, EMS providers, and local emergency management command centers.

    There are many advantages to a planned regional care model. The first advantage is to patients, who will gain the improvement in outcomes from being cared for by experienced staff (from the receptionists and housekeepers to the techs to the bedside clinicians) in a facility best
    configured for their needs. EMS services can be highly effective in transporting patients to the correct facilities as has been shown with previous successes in care for acute myocardial infarction patients and trauma victims. Correct and timely ED triage and coordinated transfer are essential to get self-transporting patients to where they need to be. Coordinated public communications from all providers as to the regional care plan can provide reassuring messages to the public AND reduce confusion and self-transport to the wrong facility.

    In terms of PPE, regionalization can result in economies of scale and multiple efficiencies in the use of PPE. Effective PPE usage requires staff training (including boosters) and inventory management that can be more effectively managed at a smaller number of facilities. Providers may be able to make better use of PPE in bedside care at a regional care center that has been reconfigured especially for COVID-19 treatment.

    Non-COVID-19 treating hospitals can play multiple supporting roles within their defined region.

    Regional COVID-19 task forces should plan especially for the needs of pediatric ICU patients. The designated pediatric care center may be different than the adult center(s). If transport to farther distant centers will be needed for pediatric patients, the planning process should start now. The new paper in Pediatrics on the child patient experience in China makes very clear that, while the relative risk of severe pediatric cases is lower, USA hospitals should expect a non-zero number of these patients. Furthermore they will most likely be ages 0-5 years old, and require specialized PICU supplies and equipment.
    CONFLICT OF INTEREST: None Reported
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    Quicker Turnaround for COVID Testing
    Saurabh Rajguru, MD | University of Wisconsin
    We need universal rapid SARS-CoV-2 testing so that hospitals can rule out COVID-19 in 24-48 hours instead of 4-5 days, so that patients can be taken out of isolation quicker and PPE is not wasted on patients who are ultimately negative.
    CONFLICT OF INTEREST: None Reported
    Conservation of Available PPE
    Shameer V K | Medical College Kozhikode
    As the number of patients with COVID-19 peak, more and more health care workers are pulled in and many are newly dealing with an Infectious disease. The only training they get about PPE is donning and doffing. Emphasis should be made about responsible use of PPE too.

    In countries like India, where the massive epidemic has not yet set in, we can conserve the remaining PPE in by

    - Restricting triage; patients don't walk or sit very close to the health care workers. Only very few who need to examine or do some procedures get closer to
    patients and they wear PPE.

    - In isolation wards/rooms, suspected patients are seen first and confirmed patients last, minimizing the number of workers in contact with confirmed patients.

    - Introduce a box with schedule so patients can self-administer medicines, to reduce the number of nursing visit for medication administration requiring PPE. A bell or phone can be arranged for the patient to call for emergency help from the isolation room.

    - Minimise parenteral administration of drugs in confirmed COVID patients.

    - Minimise cross consultations in confirmed COVID patients.
    CONFLICT OF INTEREST: None Reported
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    Disinfection followed by drying of PPE
    Ayyappa Chaturvedula, PhD | University of North Texas Health Science Center
    We know that strong alcohol (ethyl alcohol, IPA) is an efficient disinfectant for viruses (1) and data from WHO suggest heat at 56°C kills the SARS coronavirus at around 10000 units per 15 min (quick reduction) (2).

    I would like to suggest potentially a two tier protocol where:

    1. Disposable PPE are disinfected by wetting with alcohol as much needed
    2. Dry the PPE after step 1, around 60 C or above as much the PPE can handle. This not only might kill the virus but also evaporate the disinfectant more efficiently.

    It may be
    that some research studies could evaluate if only #2 is enough for the purpose. Heating in a hose air oven is probably the easiest we can do this with much less technology requirement. More studies are needed to confirm these ideas.

    References
    1. Infection Prevention and Control of Epidemic- and Pandemic-Prone Acute Respiratory Infections in Health Care. Geneva: World Health Organization; 2014. Annex G, Use of disinfectants: alcohol and bleach. Available from: https://www.ncbi.nlm.nih.gov/books/NBK214356/
    2. https://www.who.int/csr/sars/survival_2003_05_04/en/
    CONFLICT OF INTEREST: None Reported
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    additional preventative measures, in addition to hand washing
    Michele Charest, Retired RN. |
    It is almost impossible to avoid touching one's face. As the nostrils and mouth are the most likely point of contact and the closest portal of entry for the virus, I am recommending that washing one's face is as important as one's hands when coming in contact with possible sources of contamination. I would like to have this commonsense measure circulated widely.

    Michele Charest,
    Ottawa, Canada
    CONFLICT OF INTEREST: None Reported
    Place Extended Dwell IVs in Suspected COVID-19 Patients Upon Admission for Vascular Access and Lab Draws
    Noah Chodos, MD | Tufts Medical Center
    Extended Dwell IV catheters are a particularly durable version of peripheral IV that has a dwell time of ~29 days and has the added benefit that one can draw blood from them. Consideration should be given to placing these in patients with suspected or known COVID-19 to decrease the number of times that additional health care workers (e.g. phlebotomists) would have to enter the room and don PPE to draw labs.

    In an ideal scenario, a patient could have an extended dwell IV placed upon presentation with the hope that it would last them throughout admission
    for vascular access while also serving as means for phlebotomy. Nurses and physicians could work to time medications, lab collections, vital signs checks, and other care to reduce the amount of times that PPE must be utilized.
    CONFLICT OF INTEREST: None Reported
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    Gamma or E-beam Irradiation
    Brian Bucher |
    Consider utilizing either gamma irradiation or e-beam irradiation for sterilizing respirators such as N95s.

    I am not an expert in any of the relevant fields, so these are simply suggestions with links to some sites and papers (1-6) . I would also suggest contacting the authors/experts in these fields for their evaluations regarding the feasibility of using these two methods for sterilizing N95 (and other) masks, and the amount of work that would be required to demonstrate a high confidence in adequacy of the process.

    REFERENCES

    1. https://www.steris-ast.com/services/gamma-irradiation/
    2. https://www.steris-ast.com/services/electron-beam-irradiation/
    3. Efficacy of Electron Beam for
    Viral Inactivation (Nims 2015)
    https://www.longdom.org/open-access/efficacy-of-electron-beam-for-viral-inactivation-1948-5948-1000200.pdf
    4. Gamma Irradiation as an Effective Method for Inactivation of Emerging Viral Pathogens (Feldmann 2019)
    http://www.ajtmh.org/content/journals/10.4269/ajtmh.18-0937
    5. Inactivation and safety testing of Middle East Respiratory Syndrome Coronavirus (Kumar 2015)
    https://www.ncbi.nlm.nih.gov/pubmed/26190637
    6 https://www.tsinghua.edu.cn/publish/thu2018en/11490/2020/20200228205748718804992/20200228205748718804992_.html
    CONFLICT OF INTEREST: None Reported
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    Heat sterilization at lowest possible temperature
    Boyuan Wang, Ph.D. | Department of Biology, MIT
    I looked but did not find any heat-sensitivity study for COVID-19 virus, but the SARS-coronavirus can be effectively eliminated at 56-65 deg C for 30-90 minutes (1). So maybe it is worth trying to thermostat PPE at 65 deg C in an oven for 90 minutes before reusing. This obviously would not kill many bacterial pathogens so the mask should go back to the same user to prevent spreading of other diseases.

    Another potential way to kill COVID-19 without damaging the adsorption ability of the mask is dry-cleaning it using a non-polar solvent. Adsorption of virus to the
    mask is primarily through polar interactions. Solvents like perchloroethylene ('perc') should not invade these polar structures while (likely) being sufficient to destroy coronavirus.

    REFERENCE

    1. Viruses. 2012 Nov; 4(11): 3044–3068.
    CONFLICT OF INTEREST: None Reported
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    Increasing PPE supply and their Protection:
    Shushovan Chakrabortty, M.D., Ph.D. | Wayne State University, East West Pain Institute
    #1. National Level:
    The government needs to have an urgent meeting with the mask manufacturing industry which can be motivated/subsidized to produce more masks. Everything should be in "Wartime Mode" for rapid production.

    #2. Local level:
    Since Ambulatory Surgery Centers (ASCs) are closed, PPE from ASCs should be transferred to COVID-19 hospitals with appropriate compensation. Similarly, as many physicians' offices are also closing, PPE from there can be transferred to COVID-19 hospitals.

    #3. Hospital/Personal level:

    Making Face Shield:
    A transparent thermoplastic sheet or PolyEthylene Terephthalate (aka PET, PETE, PETG), precut around 12"x12" sizes with 0.02 to 0.03
    cm thickness or from a larger size,  be easily trimmed into an appropriate faceshield size (usual ranges: 7 to 8 inch length and 10 to 14 inch width). The transparent shield can be attached with a headband along with a fastener like Velcro Strap.

    #4. Alternative for Hand Sanitizers:
    Since there is a nationwide shortage of commercial brand name hand sanitizers, 70% Ethyl Alcohol on a wipe can be used and if the system needs more, its mass production can be relatively easier.

    #5. Department-Owned UV-C Decontamination
    All PPE, especially N95-type masks, can made ready for reuse after quick UV-C decontamination.
    CONFLICT OF INTEREST: None Reported
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    Use Food Prep, Welding, Construction Faceshields
    Michelle Wallace, BS | Concerned citizen, inventor, repurposer
    Many occupations use hard full face shields, which could be repurposed for medical use.

    Here are links to some examples: 

    Welding: https://www.arc-zone.com/Safety-Goggles

    Food prep:

    https://foodsafety.ecolab.com/us/food-safety/face-protection

    https://www.seton.com/safety-security/ppe-personal-protective-equipment/head-protection/faceshields-headgear.html?q=faceshield&searchcategory=redirect

    Safety glasses: https://www.safetyglassesusa.com/face-shields.html 


    Motorcycle helmets have detachable full face visors
    CONFLICT OF INTEREST: None Reported
    Batching Medications
    Valerie Vaughn, MD, MSc | University of Michigan; Regional Infectious Containment Unit Medical Co-Director
    At our hospital, the vast majority of personal protective equipment (PPE) is used by nursing staff who frequently have to enter patient rooms to provide care. As part of an attempt to conserve PPE, we looked for opportunities to reduce unnecessary entrances into patient rooms. One common nursing task is “passing meds.” We noticed that physicians often ordered medications based on reported frequency (e.g., twice daily, every 12 hours, at dinner) and that this frequency did not always need to be hard and fast. Rather, medications could often be batched. We worked with pharmacy to create a process where pharmacy would a) automatically batch medication administration times when it was clearly safe to do so (e.g., medications scheduled to be given at 6 pm and 8 pm when both could safely be given at 7 pm) and b) notify physicians when there were opportunities to reduce the frequency of medication administration (e.g., from twice daily to daily extended release). This plan was piloted on our COVID-19 unit with plans to roll it out throughout the hospital to any patient under precautions that require PPE.
    CONFLICT OF INTEREST: None Reported
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    Shopify for Personal Protective Equipment
    Sivasubramanium Bhavani, M.D. | University of Chicago
    There are several factories in other countries (including China) that have PPE supplies, and these suppliers are ready to provide the PPE at minimal cost. The problem is the current U.S. hospital procurement services are not connected with this international supply chain. In addition to the lack of connections with suppliers, hospitals are also unable to accurately measure the current need for PPE (as the pressure from this need falls directly on providers). Instead, we need an e-commerce shopify-type open marketplace for personal protective equipment. Unit directors or nursing managers should be able to directly purchase what is required for their units from these international suppliers. The unit directors/managers would have a unique billing code from their hospital, and the hospital would be billed for these purchases. This solution would directly connect the international suppliers with the people who actually need the PPE - providers.
    CONFLICT OF INTEREST: None Reported
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    Policy Strategy: Source PPE from Health Care Allies
    Joe Yun, DDS | Children's Medical Center - Dallas
    Currently there are an estimated 200,419 dentists and 71,060 veterinarians in the U.S. workforce primarily in private practice, and with that, an untapped source of PPE. One of the main obstacles to charitable giving from these offices include concerns over their ability to maintain their private practices, which operate at a high overhead. The state of Texas alone has over 14,000 private practices. While many of these offices do not possess N95s, some clinics do. Oral surgery clinics might have their own respirators and equipment. Dentists all possess surgical masks that would certainly provide greater protection than bandanas and makeshift hardware currently used in some hospitals.

    I propose the government establish a policy program that encourages these clinics to give their medical supplies in exchange for one of the following: either a direct buyback program at a discounted Medicare rate, or establish a "war bonds" style program that can be federally backed and offer some return on their interest.

    Historically, war bonds were debt securities used to raise capital during WWII. The idea was that civilians would purchase these bonds at discounted rates but with a guaranteed maturation value, and since they were backed by the federal government, there was no risk of losing the valuation of the bond. For example, a $75 bond would be guaranteed to grow at a set interest rate and valued at least $100. The bonds also controlled for inflation by restricting the amount of deficit spending; the bonds would essentially phase the artificially generated money out of market once they reached maturation.

    As many of these offices are operating in the red and still seeing patients to stay afloat, an immediate injection of capital will give them reprieve as small business loan programs roll out and also aid the immediate need for PPE. This buys time for both small offices and hospitals; the latter awaiting a slowly--but surely--snowballing manufacturing effort for medical equipment.

    Additionally, war bonds have two net benefits. The first being a spirit of patriotism and capturing the urgency of the health care crisis we face. There are many offices still operating and this offers a meaningful way for members of the private sector to contribute to a public cause. This would also force hesitant private practices to recognize the gravity of the pandemic. Second, war bonds generated a secondary market for their exchange, where individuals in immediate need of capital could sell them to one another. This reduces the overall spending on the part of the government, grants some capital reprieve in the short term for sellers of the bonds, and holders will have extra capital following cessation of the coronavirus outbreak that can return to the market.

    I've written an op-ed through Politico that gives some background onto this idea (1). I'm hoping policies that nurture innovative public-private partnerships will result in more collaboration between health care allies to develop a concerted effort in combating the disease.

    REFERENCE

    1. https://www.politico.com/news/agenda/2020/03/20/a-quick-way-to-find-more-face-masks-139103?fbclid=IwAR2HjdAY0R_wbC0AOCgA3b9JZL0c0O5dIdfmLquqDrdenMw8X5uqq82LwO0
    CONFLICT OF INTEREST: None Reported
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    Policy Strategy: PPE from Health Care Allies
    Joe Yun, DDS | Childrens Medical Center Dallas
    Currently there are an estimated 200,419 dentists and 71,060 veterinarians in the U.S. workforce primarily in private practice, and with that, an untapped source of PPE. One of the main obstacles to charitable giving from these offices include concerns over their ability to maintain their private practices, which operate at a high overhead. The state of Texas alone has over 14,000 private practices. While many of these offices do not possess N95s, some clinics do. Oral surgery clinics might have their own respirators and equipment. Dentists all possess surgical masks that would certainly provide greater protection that bandanas and makeshift hardware currently used in some hospitals.

    I propose the government establish a policy program that encourages these clinics to give their medical supplies in exchange for one of the following: either a direct buyback program at a discounted Medicare rate, or establish a "war bonds" style program that can be federally backed and offer some return on their interest.

    Historically, war bonds were debt securities used to raise capital during WWII. The idea was that civilians would purchase these bonds at discounted rates but with a guaranteed maturation value, and since they were backed by the federal government, there was no risk of losing the valuation of the bond. For example, a $75 bond would be guaranteed to grow at a set interest rate and valued at least $100. The bonds also controlled for inflation by restricting the amount of deficit spending; the bonds would essentially phase the artificially generated money out of market once they reached maturation.

    As many of these offices are operating in the red and still seeing patients to stay afloat, an immediate injection of capital will give them reprieve as small business loan programs roll out and also aid the immediate need for PPE. This buys time for both small offices and hospitals; the latter awaiting a slowly--but surely--snowballing manufacturing effort for medical equipment.

    Additionally, war bonds have two net benefits. The first being a spirit of patriotism and capturing the urgency of the health care crisis we face. There are many offices still operating and this offers a meaningful way for members of the private sector to contribute to a public cause. This would also force hesitant private practices to recognize the gravity of the pandemic. Second, war bonds generated a secondary market for their exchange, where individuals in immediate need of capital could sell them to one another. This reduces the overall spending on the part of the government, grants some capital reprieve in the short term for sellers of the bonds, and holders will have extra capital following cessation of the coronavirus outbreak that can return to the market.

    I've written an op-ed through Politico that gives some background onto this idea (1). I'm hoping policies that nurture innovative public-private partnerships will result in more collaboration between health care allies to develop a concerted effort in combating the disease.

    REFERENCE

    1. https://www.politico.com/news/agenda/2020/03/20/a-quick-way-to-find-more-face-masks-139103?fbclid=IwAR2HjdAY0R_wbC0AOCgA3b9JZL0c0O5dIdfmLquqDrdenMw8X5uqq82LwO0
    CONFLICT OF INTEREST: None Reported
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    Leverage Communities and Construction Companies
    Tovy Kamine, MD | Portsmouth Regional Hospital
    Most construction companies use N95 or P100 respirators that are reusable with disposable filters for painting and handling toxic materials or other activities that require them. These respirators are reusable and can be cleaned with alcohol and probably bleach. There are thousands of these around the country and if construction companies could donate their surplus reusable respirators (and/or community members who bought them when the crisis started) this could go a long way towards easing the shortage. It’s much better to reuse a respirator that is designed for it than one that is designed to be disposable!
    CONFLICT OF INTEREST: None Reported
    Recycling PPE used to protect the Medical Community against COVID 19 with Ethylene Oxide Sterilization
    Richard Seader, Veterinarian | Retired Veterinarian - Graduate from Cornell University College of Veterinary Medicine
    There is a very simple, inexpensive and effective way to sterilize and recycle all personal protective equipment against COVID 19. Sterilization using ethylene oxide is used by most surgical units and is readily available. It takes 12 hours and can be used on masks, gowns, plastics and any delicate equipment. I was horrified when I heard on the news tonight that health care professionals were trying to sterilize their masks by spraying them with lysol spray! Ethylene oxide sterilization provides ove kill for pathogens and provides indicators that the sterilization was complete. It can be done in bulk and the small ethylene oxide molecules penetrates materials extremely well. Please review the videos below (1,2).

    Until we can get the production of PPE up to the levels needed to fight this pandemic, ethylene oxide sterilization can provide a viable method of recycling critical PPE .

    Another topic for consideration during the COVID 19 pandemic is how to sterilize hospital rooms that contains beds and other fabrics that are contaminated with COVID 19. One solution is placing an ozone generator in the room and blasting the room with ozone. Proper ventilation is required before reentry to the room. (3-5)

    REFERENCES

    1. https://www.youtube.com/watch?v=4ZIvNylbjZM

    2. https://www.youtube.com/watch?v=M3ZICe3Vwj8

    3.  https://www.pfss.be/covid-19-disinfection-with-ozone/

    4. https://www.thailandmedical.news/news/ozone-can-be-used-to-destroy-the-new-coronavirus-and-disinfect-areas

    5, http://www.china.org.cn/opinion/2020-02/26/content_75747237_4.htm
    CONFLICT OF INTEREST: None Reported
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    Saving Protective Equipment (PPE)
    Mohamed Mohamed, MD, PhD | Cone Health Cancer Center
    The Cone Health system in Greensboro, NC took several steps to deal with the COVID-19 pandemic. We had several tents outside the Emergency Departments in many of our campuses to deal with and screen any potential patients with COVID 19 before they reach the hospital or Emergency Department for potential admission.

    At cancer centers with patients at higher risk of complications and even mortality because of their immunocompromised status, we screen every patient or staff member as they enter the cancer center. We implemented telephone screening for patients the day before their visits to make sure they
    do have any flu-like symptoms and direct them to the right place for examination or advise them to stay home for isolation as indicated.

    We also limited the number of visitors. We created a negative pressure room away from the remaining examination rooms with only one provider and one nurse daily to deal with any suspicious COVID 19 cases.

    Only these providers would require full gear PPE. N95 face mask can be reused by being placed in a brown bag with their name written on it.

    We also postponed all elective surgeries andused telephone or WebEx visits for all routine visits to decrease the traffic and exposure to other patients and staff because of shortage of PPE.
    CONFLICT OF INTEREST: None Reported
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    Potential Utilization of Reusable Gowns
    Aaron Rosenblum, Medical Student | University of Minnesota Medical School
    Reusable gowns for patients in contact isolation have already been deployed at large medical centers (1), with the primary motivation being an overall reduction in waste and greenhouse gas emissions associated with the manufacture, transportation, and disposal of one time use gowns.

    While under normal circumstances implementation of a workflow, especially the laundering process, would take time to carefully plan, there may be opportunities currently to speed this process along. It is likely that commercial laundry facilities with high throughput capabilities, such as those servicing hotels and restaurants, are currently being underutilized and could be called upon to clean
    reusable gowns. If there is not adequate stock of new gowns currently available, a pattern could be widely disseminated along with yardage of suggested material to allow for speedy production by either citizen volunteers or existing textile manufacturers.

    References:
    1. https://practicegreenhealth.org/tools-and-resources/ronald-reagan-ucla-medical-center-reusable-isolation-gowns
    CONFLICT OF INTEREST: None Reported
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    Reuse of PPE after heat inactivation
    Jonathan Angel, MD | JPS Family Medicine Residency
    Heat inactivation of SARS-CoV-2 is a highly promising and broadly applicable option to allow PPE reuse.

    Duan, et al, found that dried films of SARS-CoV had rapid inactivation at low temperatures; surfaces "were converted to be non-infectious after 90-, 60- and 30-min exposure at 56 degrees C, at 67 degrees C and at 75 degrees C, respectively."(1) Similarly, in liquids, WHO reported that 15 minutes at 56 degrees C was sufficient to produce a fourfold-titer reduction of SARS-CoV. (2)

    While the two viruses are not identical, a recent report from van Doremalen, et al, indicates the environmental stability
    of the two viruses is sufficiently similar to warrant rapid research of this option (3). Additionally, due to the temperature range of 56-75 degrees C being easily attained in a conventional dry-heat oven (commonly found in many parts of the world) or wet-steam autoclave (commonly found near surgical theaters or clinic procedure rooms) and the rapid time to inactivation, this poses an attractive option for translation to underserved health populations.

    REFERENCES

    1. Duan SM, et al. "Stability of SARS coronavirus in human specimens and environment and its sensitivity to heating and UV irradiation." Biomed Environ Sci. 2003 Sep;16(3):246-55. Accessed 2020 Mar 20. https://www.ncbi.nlm.nih.gov/pubmed/14631830.

    2. WHO Report. “First data on stability and resistance of SARS coronavirus compiled by members of WHO laboratory network.” Accessed 2020 Mar 20. http://www.who.int/csr/sars/survival_2003_05_04/en/#.

    3. van Doremalen, et al. "Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1." N Engl J Med. 2020 Mar 17. doi: 10.1056/NEJMc2004973.
    CONFLICT OF INTEREST: None Reported
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    Ozone and Microwave Sterilization, Filter Materials
    Richard Smaglick, Electrical Engineering | Engineer, Entrepreneur, former Harvard Medical School Faculty
    Ozone has been used successfully for sterilization in medical research. I've designed very high concentration ozone generators for semiconductor atomic layer deposition. In high concentrations, ozone can be quite hazardous, but when used in a controlled manner at moderate concentrations, it might prove to be very effective at sterilizing PPE. One of it's benefits is that it penetrates even the smallest spaces. Here's an example of an ozone generator being used in a medical research lab environment.

    http://www.genlantis.com/ozone-sterilizer-1.html

    I'm open to collaborating with PPE experts and others on this subject.

    Microwave
    energy as delivered by microwave ovens has also been shown to have some efficacy in deactivating viruses (1).

    Although N95 respirators often contain one or more metal parts, at least in some cases these do not generate sparking in microwave ovens. The tendency for metal to spark in a microwave oven is highly dependent on the shape of the metal. If such a technique is viable, it will need to be done in a controlled manner accounting for the mask type. The positioning of the mask in the microwave will be an important factor. The number, volume and placement of masks and other items will also be important factors. It may be wise to use a separate microwave oven for every healthcare worker. Most importantly, the efficacy of the approach will have to be proven beyond a doubt and thoroughly reviewed.

    https://www.youtube.com/watch?v=EHJez-0XYvE&feature=youtu.be

    https://www.youtube.com/watch?time_continue=1&v=jWOxnpmw7Dk&feature=emb_logo

    I'm open to collaboration on the microwave approach.

    N95 respirators are often made from non-woven polypropylene fabrics. Although I don't know of a domestic source yet, here's a Chinese source.

    https://cihengnonwoven.en.made-in-china.com/product/TNyJfvWdZmhc/China-Custom-Medical-Respirator-80GSM-N99-N95-Filter-Material-for-Making-Dust-Mask.html

    Domestic sources should be identified.

    Blisters packs, the clear plastic sheet formed packages often used for electronics and toys among other things, are made with a very simple vacuum process that can be brought on line very quickly. This approach to thermal forming might yield vented masks to which the N95 filtering material could be applied. A soft foam gasket could be applied to the edge in liquid or paste form, robotically, as a reactive foam.

    I expect the domestic garment industry in NJ and elsewhere could very quickly produce many surgical style masks if the right materials were available. I also expect that the filter material would hold up well to washing and could be paired with other washable materials.

    Certain high quality vacuum cleaner bags are designed to filter out particles in the 0.3 micron size range, which is the particle size N95 respirators are designed for. Those materials and the manufacturers of these bags might be considered as supply chain options.

    REFERENCES

    1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5114683/#!po=17.3077
    CONFLICT OF INTEREST: None Reported
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    Infusion Pumps Outside Rooms
    Ji Rhee, MD | GBMC
    1. This was an idea shared on the USA COVID Facebook group: to have infusion pumps outside the room with long extension tubings to adjust drip rates from outside the room to avoid doning/doffing PPEs repeatedly for adjustments.

    2. At ours and many other institutions, a facial mask with an eye shield is worn over the N95. If N95 was thought not to be contaminated, one. can remove the facial mask and toss that away but keep the N95 to reuse later.
    CONFLICT OF INTEREST: None Reported
    Staff with Natural Immunity Spare Protective Gear
    Bruce Wexler, Harvard BA, AECOM MD | Yale University School of Medicine
    Isolation and treatment centers need to be staffed to the maximum extent possible by people with natural immunity after recovery from COVID-19 who can work without PPE. There are two sources. First are community volunteers who have recovered from infection. They can be immediately deployed to isolation and treatment centers. Second are young healthy soldiers deployed to isolation and treatment centers, housed in their own hotels with state-of-the-art treatment floors, quarantined from the general community, and with rest, exercise, food and other supports that enhance immune response. Data from China and new data from 1000s in Korea show that >95% of healthy adults under 30 will recover quickly and mortality was 0% in this group in Korea. They will rapidly constitute a large group of caretakers who do not need PPE. Although most among these two groups with natural immunity will lack medical training, they can immediately assume many positions in diagnostic and treatment centers, and nearly all positions in isolation/quarantine centers where patients with less severe conditions are isolated, monitored and cared for much more effectively than with voluntary home quarantines. As with war time mobilizations, selected individuals can be provided with training to assume more and more functions. Recruitment of retired healthcare workers to provide urgent help now is exactly the wrong thing to do. They will require PPE, many will still get infected, spread COVID-19 when they return home, and because of their age be more likely to have severe illness further burdening the delivery system.
    CONFLICT OF INTEREST: None Reported
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    Treatment of N95 mask with salt water to allow reuse
    Bharti Gangwani, MD | Boston Children’s Hospital, Harvard Medical School
    I came across an article published in 2017 that reports the development of a universal, reusable virus deactivation system by functionalization of the main fibrous filtration unit of surgical mask with sodium chloride salt (1). The salt coating on the fiber surface dissolves upon exposure to virus aerosols and recrystallizes during drying, destroying the pathogens. The authors found that salt-coated filters proved highly effective in deactivating influenza viruses regardless of subtypes and following storage in harsh environmental conditions.

    This might allow reuse of the limited masks that we have. We would need validation of this technique to see if
    it is effective and allows reuse of masks. Also came across a video on YouTube explaining the technique.

    Interesting concept but needs further testing and validation!

    REFERENCE

    1. https://www.nature.com/articles/srep39956
    CONFLICT OF INTEREST: None Reported
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    Sanitation for Recycling
    Steven Scott, BS Industrial Technology | Independent contractor / medical narrator
    I see an opportunity to reach out to the food canning industry. Their use of gamma radiation in bulk sanitation offers an opportunity to recycle/reuse most PPE with assurance of complete disruption of complex organics without damage to the equipment.

    Biohazard waste handling and transport infrastructure is already in place.

    The only significant steps to develop are appropriate packaging for reissue and a standardized marking system to indicate previous use and allow discard after a set number of uses.

    Throughput would likely be limited only by administrative functions such as traceability & related documentation.
    /> Praying practical solutions are found soon.
    CONFLICT OF INTEREST: None Reported
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    Think Blue Collar for N95 Masks
    Michele Trumler-Gleason, Medical Doctor | Ophthalmologist in Private Practice
    I practice in Grand Island, Nebraska. We have a shortage of N95 masks.

    My husband is a farmer and went around to the NAPA stores and hardware stores in surrounding smaller, more rural towns. (In the larger towns the public had bought them for themselves.) They had industrial N95 masks. I realize that these are not medical grade, but they are a safer option for providers to wear than just a surgical mask. We contacted local farmers who had boxes of them because they use them on the farm to clean out grain bins.
    The local ethanol plants and industries and industrial suppliers had some.
    CONFLICT OF INTEREST: None Reported
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    Ponchos and Seamstresses
    Grace Terrell, MD MMM | Eventus WholeHealth, LLC and Wake Forest Baptist Health System
    Eventus WholeHealth is a medical group of greater than 200 providers of primary care, behavioral medicine, podiatry, audiology, and optometry services for 500 skilled nursing facilities and assisted living facilities in five states. Although skilled nursing facilities have a limited supply of personal protective equipment, assisted living facilities typically do not, yet still provide residential services for populations highly vulnerable to COVID-19. Because traditional PPE suppliers have prioritized their usual customers such as hospitals and ambulatory providers, Eventus has been unable to secure adequate PPE through the usual supply chain. However, inexpensive disposable plastic rain ponchos have been available via amazon and may be worn in rooms of patients at high risk for the corona virus. Our providers do not perform procedures such as intubations where N95 masks would be necessary. Therefore, we have been able to provide dense-cloth masks to our providers as a results of volunteer seamstresses in our community, providing some droplet protection. We look forward to the supply of PPE expanding, but in the meantime we are grateful to our community volunteers who have allowed us to serve patients in the assisted living facilities and suspect other communities can muster this volunteer resource to assist.
    CONFLICT OF INTEREST: None Reported
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    Inpatient eConsults to reduce non-essential patient contact
    Sharon Rikin, MD, MS | Montefiore Medical Center - Albert Einstein School of Medicine
    eConsults allow the primary team caring for a patient to request and receive recommendations from specialists without requiring the specialists see the patient in-person. This communication is documented in the medical record similar to a formal consult.

    While traditionally this has been used in outpatient settings, this model of care can easily be brought inpatient. Substituting eConsults for in-person consults reduces the number of PPE used by specialists. It also has the potential added benefit of reducing spread of COVID19 by reducing unnecessary contact. An additional benefit is expanding the capacity of physicians to
    care for more patients during this surge as eConsults usually require less time than an in-person consult.
    CONFLICT OF INTEREST: None Reported
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    Prefilters, Washable Cloth Masks, Universal Precautions
    Peter Libre, MD | Columbia University Irving Medical Center
    "Prefilter" protocols could greatly extend our mask supplies. NY Presbyterian has just issued this directive: "The use of a surgical mask over the N95 respirator can prevent droplet contamination of the N95. Thus, if the N95 is covered as above, it can be reused multiple times until visibly soiled, contaminated, or wet or the wearer is unable to pass a fit check.

    The same logic would permit a washable cloth mask to cover a surgical mask, permitting the surgical mask to be used many days. The owner of each surgical mask could UV disinfect it by laying it in
    direct sunlight for a few hours on each side. Someone with a sewing machine could make 30 masks a day, so 500 community volunteers could produce 60,000 in 4 days.

    Separately, I am extremely concerned that some staff and patients are permitted to have uncovered faces within hospitals. The prevalence of infection and transmissibility by asymptomatic persons requires universal droplet precautions. A washable cloth mask would block exhalation of droplets by talking, coughing and sneezing, though it is not as effective as a surgical mask for blocking inhalation of droplets. A cloth mask should probably be changed every 2-4 hours since moisture and time could permit droplets to reach the exterior.
    CONFLICT OF INTEREST: None Reported
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    Coordinated Response with Experts in cCarge
    Andrea Demeter, ID/Internal Med Physician | Community Not For Profit Hospital
    Under ideal preparedness conditions, what we would need to be ready for something like this:

    1. Modular negative pressure containment units with capacity for unlimited interconnectedness and expansion (Neal Stephenson's novel Seveneves has described something similar for space) powered by renewable energy and batteries, antechambers between, HEPA filtration.
    2. Immediate and swift logistical plans for rapid risk stratification and definitive answers at or close to point of care. Setting these modular units up for testing and treatment as soon as possible.
    3. Ability to amplify production of critical supplies like PPE / test kits / ventilators by
    retooling fully automated factories (Elon Musk's Tesla plants come to mind).
    4. Stockpiles of critical building materials for #2 above (reagents, raw materials) or the ability to change testing and isolating protocols
    5. Experts in charge (scientists, engineers, virologists, logistics experts) when an emergency is declared.

    Unfortunately my understanding from my engineer friends is that is difficult to design a de novo industry producing N95 masks with 0.3 micron filtration limit acutely (not impossible though). #4 is also something that cannot be forced upon in a time of pandemic. #1 and #5 are scalable (and #2 follows from #5). Everything I have seen during this pandemic from the best of humanity from all over the world; there is no dearth of goodwill, we are not wanting for really great ideas and innovation, but for a unified and coordinated response in the face of what could be a catastrophic event.
    CONFLICT OF INTEREST: None Reported
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    More about UV decontamination
    Eva Guinan, MD | Academic Hospital Center
    The potential for implementing UV decontamination is well discussed in a prior comment. Another way to implement this would be to explore the wavelengths possible with research or even pharmacy hoods. This would require turning the masks, but has the advantage of using existing UV sources in a setting where airflow can be regulated to be protective. There is existing literature on the use of UV and masks that provides useful data by mask manufacturer length of irradiation which can further guide institutions that chose to explore this approach.
    CONFLICT OF INTEREST: None Reported
    Sterilization Methods for Masks and Face Shields.
    Simon Mendez, Internal Medicine. | Jacobi Medical Center NYC
    All our hospitals likely have vapor, gas, and radiation sterilization equipment in the OR. There are packages and marker tags designed to ensure sterilization of endoscopes, surgical material. One of these methods can be used to sterilize a pool of masks, goggles, and face shields that are not visibly soiled. Each health care provider can have several surgical masks to use during the day and placed on a bag for decontamination at the end of shift. The same masks can be given to this provider the next morning. This would depend on testing that sterilization does not deteriorate the physical integrity of the mask. This idea may not apply to the N95 respirators due to the need for a tight fit and filter integrity.
    CONFLICT OF INTEREST: None Reported
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    Could High Quality Home AC Filters be Modified into Masks?
    Robert Meacham, MD | Baptist Memorial Hospital - Union County, MS Emergency Dept
    The COVID-19 virus particle size has been reported as being in the 0.06 - 0.140, or more specifically in the 0.07 - .0.09 micron range. But human respiratory droplets actually carrying the pathogen range from less than 10 microns (“droplet nuclei”) to greater than 60 microns (“large droplets”). Per information from a WHO publication, one sneeze can release as many as 40,000 droplets in the 0.5 - 12 micron range. A cough releases up to 3,000 droplets, which is equivalent to an amount released by normal talking for 5 minutes.

    An N95 mask is designed to block at
    least 95% of particles 0.3 microns in size or larger. So even a properly fitted N95 mask does not completely eliminate the risk of illness or death. It works by “tortuous path”, removing particles by impact and absorption of the particulate into the filter by trapping particles between the fibers of the mask.

    High quality air conditioning (AC) filters work the same way and might be equal to this level of protection. AC filters are given MERV ratings. This stands for Minimum Efficiency Reporting Value. The scale (from 0-16) was designed to represent the worst case performance of a filter handling particles in the range of 0.3 - 1.0 microns. The higher the MERV rating, the better the particles are captured. A MERV 16 filter captures more than 95% of particles over the full range from 0.3 microns and larger. This is equivalent to an N95 mask.

    I have a 20x25x1 inch AC filter in my house that was made by 3M, purchased at Lowes. It is a “Filtrete Ultimate Allergen 1900”. It has a MERV rating of 13. It shows that it removes 62% of particles in the 0.3 - 1.0 micron range, 87% in the 1-3 micron range, and 95% in the 3-10 micron range. 3M also makes an “Filtrete Ultrafine Particle Reduction 2800”, with a MERV of 14, which would have even better performance. These aren’t quite up to N95 level protection, but in a pinch, are certainly better protection than a regular surgical mask can offer.

    Could these filters possibly be taken out of their square cardboard AC filter frames and cut into makeshift masks?
    CONFLICT OF INTEREST: None Reported
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    Speed up testing, identify necessary staff, triage inpatients, increase virtual visits
    Ankit Mangla, MD | Case Western Reserve University School of Medicine
    I propose a 4 stage policy for managing shortages

    1. Speed up testing- turnaround time should be less than 12 hours (possible here in Cleveland, Ohio where we have in-house testing)
    Impact: It will take negative patients out of the system faster and reduce the need for observing them for days. This will single-handedly reduce the need for PPE.

    2. Identify necessary staff- Identify a group of people who will work in 8-hour shifts to give emergency care to patients suspected of COVID-19.
    Impact: It helps to log how much PPE is required for each shift and inflated
    demands are not made on a particular shift. It helps in rationing what we have. A principle I have seen to great effect from my service days.

    3. Triage and increase virtual visits- So far epidemiologic data shows that 80% of patients have mild to no symptoms. Such patients do not need multiple teams visiting them. A virtual monitor can be assigned and a single physician for 20 patients to examine them (if need be). All other teams can have virtual visits.
    Impact: Lessen the number of physicians and the need for PPE.

    4. Strictly follow protocol- Cancel all elective procedures (surgical or medical)- Insurance companies should stop payments for all elective procedures unless they deal with life-threatening conditions (like cancer treatment).

    Nothing beats old-style hand washing. Personal hygiene is important. This does not replace PPE but hopefully would reduce transmission.

    Big companies should step in to start making equipment for the healthcare industry. Desperate times call for desperate measures.
    CONFLICT OF INTEREST: None Reported
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    High School Biology Teachers could be a Source of Latex Gloves.
    Mark VanDerwater, Ed.M. | Orchard Park High School
    The mandatory biology course in the high school where I teach normally does a fetal pig dissection and we offer an anatomy elective. I estimate that we have nearly 100 boxes of 100 latex exam gloves on hand. I imagine this is true for thousands of high schools across the country. I suggest communicating with state education departments, the National Science Teachers Association, and the National Association of Biology Teachers.

    Likewise, Science Education suppliers may also stock other basic medical supplies.
    CONFLICT OF INTEREST: None Reported
    Using racquetball/sports glasses, bandana covers, and RN + MD workflow changes
    Brian Lichtenstein, M.D. | Sharp Memorial Hospital, San Diego, CA
    Racquetball and other sporting glasses provide significant eye protection and are inexpensive. Cleaning may be easily performed with soap and water.

    Clearly masks (both disposable surgical and N95) are a precious commodity, both for source control and prevention, which has complicated decision making about use and reuse. Personally I think 100% of our workforce should be wearing a mask continually while on the job. There is no question that we will not be able to identify all COVID cases among patients. Furthermore, risk of exposure will continue in or communities when our staff return home. Best available research has
    led all to presume that asymptomatic spread is likely a common mode of transmission. If so, we should expect all sites of care will have prodromal or asymptomatic staff working who may spread this infection before clinical recognition and isolation from work.

    To that end, I believe all medical staff should be issued a single mask of any type, to be worn continuously throughout time in high-risk settings, e.g. hospitals or clinics where COVID patients may seek care. Ideally reusable protective eyewear such as sports googles should also be issued. If a mask is visibly soiled or no longer viable due to extended wear, a replacement mask should be provided.

    A few ideas have come up in our hospitalist group in recent days to augment our existing/dwindling supplies:
    1. Using disposable maps with a loose bandana cover to limit surface contamination of a surgical or N95 mask, mitigating droplet contamination to provide continued and/or multiple uses.
    2. Creating and using cloth masks, made from bandanas, t-shirts, etc. I've included some references below that were previously conducted discussing efficacy of cloth masks and different material. As other commenters have already noted, multiple templates are available online. Community members could donate time/resources to crowdsource the work. Potentially these could be laundered in currently available linen services used by hospitals.

    Beyond the above, to reduce waste, here are a few workflow proposals for MD + RNs that we’ve also discussed/implemented:
    -Placing IV pumps externally to patient rooms with extension tubing into rooms
    -Minimizing rounding on patients to one MD daily or possibly just televisits if clinically appropriate
    -Stopping routine vital sign checks between 10P-6A for stable floor patients (with or without COVID)

    REFS:
    https://bmjopen.bmj.com/content/5/4/e006577
    https://www.ijic.info/article/view/11366/8308
    https://www.nature.com/articles/jes201642
    https://academic.oup.com/annweh/article/54/7/789/202744
    https://bmjopen.bmj.com/content/5/4/e006577.short
    CONFLICT OF INTEREST: None Reported
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    Storing N95s immediately after use for future use
    Cheryl Conner, MD | JBVA Hospital
    Some of my fellow hospitalists and I are preserving N95 masks by removing them and placing them immediately in a brown paper bag instead of throwing them away. The bag is then labeled with the patient's last name and the date. These bags are then being stored in our locked offices. When a patient's test result returns as negative, the masks used in that patient's room are immediately available to be reused. If the patient's test comes back positive, then the masks used in their room are reusable a number of days later. Based on the time that the virus can live on surfaces (see references below), it should be safe to reuse them again 5 days later. On the conservative side, I am planning on reusing them after 7 days.

    This strategy involves having a supply of paper bags, a place to store them, and enough masks to get through a week--this number could vary quite a bit depending on many factors. Once our hospital switches to Covid-only wards, one mask could be worn an entire shift.

    My sincere hope is that enough new masks are manufactured and distributed that I never have to reuse the masks I've been storing. As that seems unlikely to happen anytime soon, I am happy that I am building a supply of masks that can be safely used as soon as next week.

    REFERENCES

    1. https://www.journalofhospitalinfection.com/article/S0195-6701(20)30046-3/fulltext

    2. https://www.nejm.org/doi/10.1056/NEJMc2004973
    CONFLICT OF INTEREST: None Reported
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    Community-Produced PPE?
    Ramie Fathy, Medical Student | Perelman School of Medicine at the University of Pennsylvania
    I have heard of several initiatives where alternatives to traditional PPE using high-quality materials are produced in the community and transported to hospitals. For example, some have advocated for 3D printing masks or ordering mylar and elastic to construct facemasks. I've seen other social media posts about crafting gowns from fabrics to be shared with HCWs on the frontlines. I've heard that Lysol is a sufficient disinfectant for the masks and that gowns could be disinfected per usual hospital gown-disinfection protocol -- is this true?

    Similarly, in Philadelphia, students have had the extremely clever idea to reach out to
    art museums to request the gloves they use in their conservation departments. Another source that has proven fruitful is requesting masks, gloves, and testing reagents from research labs associated with the universities that host each hospital system.
    CONFLICT OF INTEREST: None Reported
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    Colonized patients
    Hannah Kocik, BSN, RN | United Health Services
    My institution’s infection control department has now implemented only standard precautions for patients with colonized MRSA and VRE (ESBL not included). Unless there is a draining wound with MRSA for example, no gowns will be used. We currently use washable isolation gowns, not disposable. This type of protocol is already implemented at some institutions regardless of the current shortage.
    CONFLICT OF INTEREST: None Reported
    Have Effective and Established Bidirectional Communication Channels with Frontline Staff
    Karleen Giannitrapani PhD MPH, (PhD-Org behavior) | Stanford University/ Ci2i VA Palo Alto
    Hospital leaders and decision makers.

    If we are truly facing a supply shortage and are not able to keep up with demand, one of the most important thing leaders can do (apart from obviously spurring industry to ramp up production) is realize that front line clinicians are looking to their facility leadership for real guidance at this time. Have effective and established communication channels with frontline staff. Many frontline clinicians are very scared. Many are making great personal sacrifices to show up for the patients served in your facilities. Frontline staff need coordinated guidance and functioning communication channels with
    updated policy and process information.

    Not having PPE is a resource problem. How to face that problem is as much a process problem as it is a resource or policy problem. Here are a few recommendations after discussion with occupational health providers and clinicians from diverse sites:

    Site
    1) Designate a point person who will be responsible for distributing site-specific PPE usage guidelines at the site
    2) Designate a point person who can be contacted if there is uncertainty about resources or current process
    3) Prioritize PPE for employees that fall in OSHA designated “high risk and very high risk” categories.

    JAMA
    4) Provide a forum for people to rapid share/disseminate/publish their local efforts (both what helps and goes well and what doesn’t go well). Encourage sharing of failures and negative findings so that we can learn collectively faster.

    Other
    5) Create structured venues for information sharing to facilitate shared learning at local site, organization, medical community, and national levels.
    6) Ensure task forces handling these issues are multi-disciplinary.
    7) Facilitate as much psychological safety as possible so employees at the site feel encouraged to raise ideas, concerns, and failures to leadership.
    CONFLICT OF INTEREST: None Reported
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    Eye Mask for Surgical Mask
    Tarek Naguib, MD | Texas Tech University Health Sciences Center in Amarillo
    I use an eye mask, usually used as a sleeping aid, in place of the surgical mask whenever the hospital cannot provide one. The mask applies firmly, has a decent seal since it blocks light, is thicker than the surgical mask and can be washed and dried for reuse with reliable durability.
    CONFLICT OF INTEREST: None Reported
    New PPE Sources
    Kelly Cann, MD |
    Many colleges and universities use PPE in their class and research labs including gloves, masks, and even goggles or face shields. Medical and health professions schools also use this kind of PPE and N95s for simulations and fit testing. Given that many of these institutions have closed their doors for weeks or even the entire semester, they could donate the unused supplies to local hospitals. Colleges and universities also have cleaning supplies that could be donated.
    CONFLICT OF INTEREST: None Reported
    Test Copper Sulfate (CuSO4)
    Barry Saver, MD, MPH | Swedish Family Medicine, Cherry Hill
    N95 (and other) masks are getting donned and doffed repeatedly in 1 day, subjecting caregivers to risk of facial cross-contamination; overnight sterilization with ethylene oxide won't fix that. A persistent treatment that accelerated viral inactivation would lower that risk. Cu2+ ions have been shown to increase degradation of lipid membrane-coated viruses. It would be quick & cheap to test if N95 masks sprayed on the outside with CuSO4 solution and allowed to dry inactivated the virus much faster; if so, then we just need to figure out how low a concentration still works and make sure that the amount of CuSO4 that ends up being inhaled is safe.

    Maybe it's time to get blue instead of feeling blue!
    CONFLICT OF INTEREST: None Reported
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    Infrared Cameras to Measure Temperature
    Mikhail Kats, PhD, applied physics | Electrical and Computer Engineering, University of Wisconsin-Madison
    Infrared cameras can be used to remotely measure/monitor body temperature. The function is the same as non-contact infrared thermometers (e.g., forehead thermometers), but because of the imaging capability there is no need to aim precisely, and they can be used from across the room.

    As of this writing (March 20, 2020), there appears to be no shortage of relatively inexpensive infrared cameras (~$500). There are also add-ons to smartphones that can be purchased for ~$200; these infrared cameras have relatively low resolution, but should still be good enough to measure forehead temperature from across the room.

    One
    can even imagine using infrared cameras to quickly measure the forehead temperature of many people, e.g. dozens of people in a waiting room.
    CONFLICT OF INTEREST: None Reported
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    Preserving PPE
    Kimberly Vogelsang, Emergency Medicine | Tucson Medical Center
    I have been looking into this for the past week as to the best solution to preserve disposable N95 masks.

    The best proposition I came up with is saving 3-5 N95 masks and placing them in paper bags. Then rotating through the masks giving each one 72 hours in between each use. COVID reportedly survives on plastic and metal surfaces for up to 72 hours. So if you can cycle several masks through a rest period, potentially the risk of contamination can be minimized.

    Unfortunately UV light degrades the plastic in N95 masks compromising the integrity (1).
    /> Freezing masks just preserves the virus (which makes sense since the freeze samples in viral media for future analysis) (2)

    I'm pretty sure dunking disposable N95 masks in bleach baths (or spraying) does not help maintain the integrity of the mask either.

    REFERENCES

    1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4699414/
    2. https://www.newscientist.com/article/dn10676-can-flu-viruses-survive-winter-in-frozen-lakes/
    CONFLICT OF INTEREST: None Reported
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    Remote Home Monitoring
    Rachel Umoren, MB.BCh, MS | University of Washington
    Hospital systems can leverage telehealth and wearable sensors to facilitate timely discharges and home monitoring. The use of inpatient telehealth should be expanded to provide supportive services and conserve personal protective equipment (PPE). The availability of home monitoring would decrease the need for hospitalization for both COVID-19 and non-COVID 19 patients, decreasing the burden on the healthcare system. Wearable technologies and smart devices in the home can integrate with the hospital’s electronic health platform providing real-time information on the patient's status.
    CONFLICT OF INTEREST: None Reported
    Self-monitoring and Phone Communication
    Julien Vanderhulst, MD | University Hospital Brugmann, Université Libre de Bruxelles, Brussels, Belgium
    For selected patients outside the ICU (the majority of patients with COVID-19), self-monitoring of some parameters (oxygen saturation, temperature, glucose level or even blood pressure) could minimize unnecessary entering and exiting the patient’s room, thereby saving some PPE.

    Also phone communication with the nurses/the physicians instead of the classical bell system in patients' rooms could help understand the patient’s needs before entering the room and similarly avoid unnecessary utilization of PPE and potential exposure to the virus.
    CONFLICT OF INTEREST: None Reported
    Can we take droplet precautions to the community? As a sustainable way forward
    Robin Cherian, MBBS MRCP | NUHCS, Singapore
    We have to rethink the problem. The real issue driving the pandemic is involuntary hand-face contact. This is the critical and final step in the chain of contact transmission which we should try to target. Temporal and physical social distancing is not helpful if everyone is united by shared contaminated surfaces.

    if individuals can protect themselves in a community by protecting their own faces (deliberate barrier over the face) from others and from their own contaminated hands, we may be able to stop the pandemic.

    A motorbike rider protects his vulnerable area by using a helmet,
    not by staying off the road. In war, you can either shoot down every arrow aimed at you or elegantly use armour.
    CONFLICT OF INTEREST: None Reported
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    Consideration of robotics and virtual visits in a Pandemic
    Carolyn Kaloostian, MD MPH | University Hospital
    These unusual times call for innovative, thoughtful, and expedited actions. Plans to secure PPE in times of surge and crisis are vital to the health of our frontline providers and their families. CDC has recommended various options based on the level of surge and availability of PPE, including use of bandanas and scarves (1). The need is clear. We need more time for our system to complete research and development for evidenced-based prevention and treatment. We must protect the safety of our providers despite expected surges.  Can those who have antibodies to this novel coronavirus be protected from reinfection? (2) This seems to be unclear. Answers could help us optimize providers of COVID units to be those with possible immunity in times of protective equipment shortage. Also, strong consideration of robotics, virtual visits, and larger scale virtual ICU care to minimize need for as much PPE at this extraordinary time may be warranted (3-4).

    References:
    1.CDC, Strategies for Optimizing the Supply of Facemasks, March 2020
    2.Le et al, Coronavirus infections and immune responses, J of Medical Virology, Jan 2020
    3.Myers et al, The Virtual ICU: a New Dimension for Critical Care Nursing, Critical Care Nursing Clinics of North America (2008), vol 20 (4), 435-9.
    4.Parke et al, The Feasibility and Acceptability of Virtual Therapy Environments for Early ICU Mobilization, PM&R, Feb 2020
    CONFLICT OF INTEREST: None Reported
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    Getting more Masks
    michael stalker, CFA | Concerned Citizen
    The American public has been told to NOT wear masks. Yet we see citizens of China, S. Korea and Taiwan, countries that have successfully mitigated the virus, wearing masks. This creates a medical authority credibility problem.

    I have about 8 masks and am afraid to use them due to the social stigma. I do not want to be perceived as part of the problem, yet I want to protect myself and go about my business. I do not know who is mildly inflected, showing few symptoms and spreading the virus, it could be anyone. Maybe me at some point,
    given the projections. There's a good chance I or my wife may get COVID-19. What's the healthy spouse supposed to do to protect themselves as a caregiver?

    The medical authorities need to offer mask reuse techniques to citizens that have masks and at the same time ask those citizens to drop off their extra masks at designated medical facilities.

    Show me how I can reuse my mask and protect myself and family. I'll gladly give up extras which I purchased at a hardware store.

    Could I disinfect my mask by using a spray bottle to mist it with an alcohol or a hydrogen peroxide solution and let it dry?  Could I heat the mask (dampened?) in a toaster oven or microwave and kill the virus? How would I make a washable, reusable mask from readily available materials at home? Is there a sewing machine pattern that could be provided?

    Would the CDC or some other organization put up vetted mask reuse solutions on its website?

    Social distancing and shelter in place are, in part, mask shortage responses. And it's crushing the economy.

    Thank you to all the medical professionals that are doing their best to help us through this crisis! We are all in this together.
    CONFLICT OF INTEREST: None Reported
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    N95 and PPE in Pyxis-like system
    Julia Kendrick, MD | LSUHSC New Orleans
    At my hospital, people have been stealing large quantities of PPE since it is not under lock and key. If N95 masks and other crucial PPE could be kept in a Pyxis-like system, requiring an ID, password, and inventory count, it might prevent stealing and hoarding.
    CONFLICT OF INTEREST: None Reported
    UVGI Robots, UVGI In other areas (Air handler, Elevator, Restrooms)
    Kristin Stitt, DNP, APRN | Consultant, Supply Chain
    Ultraviolet germicidal irradiation (UVGI), particularly UV-C, has been shown to irradiate viruses. Robotic cleaners are an option for disinfection and cleaning patient care areas; potential should be explored for additional applications as well, including high traffic areas (elevators, restrooms) with the ability to engage UV light when not in use, as well as in air handlers.

    In addition to effectiveness and efficiency, utilization of this technology would decrease human workload, and potential exposure.

    Also, consideration of swimming goggles for eye protection (tight seal, good visibility, reusable).
    CONFLICT OF INTEREST: None Reported
    Two strategies to reduce hospital census during SARS-nCoV-2.
    Jeremy Faust, MD MS | Brigham and Women's Hospital, Harvard Medical School
    The use of personal protective equipment is related to how many COVID-19 patients are able to be effectively isolated outside of hospitals. The fewer patients we admit, the less PPE we use.

    I therefore propose the following two suggestions, (both of which I have published in the Washington Post, but feel that the JAMA audience might find interesting).

    1. A temporary change in litigation standards in every state that changes the medical malpractice standards to gross negligence or malice (1). Physicians need the confidence to discharge low-yield admissions during this time, without fear of future
    legal exposure. This not only conserves hospital beds, but it decreases the turn-over of PPE that is necessary to prevent nosocomial infection.

    2. The federal government should offer leases to hotels for use as isolation facilities for asymptomatic and mild cases of SARS-nCoV-2 / COVID-19 (2). Home isolation is problematic because of community transmission. This policy is an in situ economic stimulus by keeping these businesses open and their employees working, and provides a reasonable mechanism for the United States Federal Government (and governments elsewhere) to create covid19-dedicated facilities that match the World Health's Organization recommendations. This too limits the need to utilize PPE at home or in other facilities which do not offer single-occupancy isolation in any practical sense. Because of new HHS/CMS rules, these dedicated facilities need not provide medical care, and EMTALA does not apply.

    REFERENCES:
    (1) https://www.washingtonpost.com/opinions/2020/03/15/make-this-simple-change-free-up-hospital-beds-now/
    (2) https://www.washingtonpost.com/opinions/2020/03/20/coronavirus-is-upending-society-here-are-ideas-mitigate-its-impact/
    CONFLICT OF INTEREST: None Reported
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    Preserving Personal Protective Equipment in Academic Hospitals
    Anusha Bhat, MD | Baystate Medical Center, Springfield, MA
    During the current situation with the evolving crisis around COVID-19, preserving Personal Protective Equipment’s (PPE) is of great importance. In efforts to mitigate the same, our hospital (an academic institute) has planned to avoid exposure of students, which includes banning residents, nursing students, pharmacy students, and advanced practitioner students to care for COVID-19 suspected or confirmed cases. The idea behind this step is one, to prevent unnecessary infectious exposure to students, and, second, to prevent more than 1 PPE being utilized per patient encounter (as every case seen by a student, also needs to be supervised by an attending physician or a senior healthcare provider). With this idea, we have been able to utilize PPE judiciously.
    CONFLICT OF INTEREST: None Reported
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    Cycle Through Masks
    Daniel Ginsberg, MD | MultiCare Health System
    Studies show that the Coronavirus can last up to about 3 days on surfaces. An individual could be issued 4 masks and 4 storage boxes (or hooks on a wall if space allows). At the end of the day the mask would be put back in place and the next day they would use the next mask (or one could could use 8 masks and 8 storage locations to change mid shift) without fear of the mask being contaminated as it will have been 4 days since last used. Depending on the mask used a decision would need to be made on how many times it could be used.

    The masks and storage containers could be numbered or lettered, and possibly have the user’s initials to help match them up. On the storage container a piece of paper could be used to log the date each was used. That would help if the user forgot which mask they last used, and would help track when the mask needed to be disposed.
    CONFLICT OF INTEREST: None Reported
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    A Two-Pronged Approach: Harnessing Industry and Individual Talent
    Lynn Daboul, Medical Student | Cleveland Clinic Lerner College of Medicine
    During World War II, we saw American women step up to take factory jobs to help the war effort, allowing for the mass production of weaponry and other war needs. Repeatedly, we have heard this pandemic likened to times of war. As such, we need to get an "all hands on deck" approach to maximizing the supply of PPEs. First, industries that are facing slow business can be incentivized to switch to PPE production. We have seen this work today in New York, with fashion designer Christian Siriano temporarily switching from fashion to PPE production. With more incentives, this can be encouraged at a state-by-state or national level.

    Second, for the many Americans who are now encouraged or mandated to stay at home who want to help out, hospitals and other groups can provide the materials and instructions needed to manufacture PPE at home safely and effectively. This can be on a volunteer basis, or possibly even for pay-- especially as unemployment rates are beginning to skyrocket and many Americans are looking for work to do in this period.

    We have the workforce to do this, but the workforce needs to be provided materials, instructions, and incentives in order to join together in producing PPE.
    CONFLICT OF INTEREST: None Reported
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    Automated UV-C Disinfection System
    Matthew Rosengart, MD MPH; Janet S. Lee, MD | University of Pittsburgh
    SARS-CoV-2 can be inactivated by UV-light and automated UV-C disinfection machines could provide a method for decontaminating PPE on a large scale and extend the use of PPE such as N-95 masks. As previously mentioned in the online comments, this method could conceivably enable the reuse of PPE. If UV-C light can extend the use of one N-95 mask by 2 or 3 times, the supply of PPE available for each healthcare worker increases by 2- or 3-fold. Prior studies have shown the efficacy of an UV-C light system to inactivate viruses such as SARS-CoV-1 and MERS-CoV on surfaces.(1,2) Given the recent findings of aerosol and surface stability of SARS-CoV-2 is similar to that of SARS-CoV-1,(3) UV-C light lamps could conceivably be employed in dedicated COVID-19 wards or units as part of a broader decontamination strategy to mitigate the burden of virus.

    References:

    1. Tseng C.C., Li C.S. Inactivation of viruses on surfaces by ultraviolet germicidal irradiation. J Occup Environ Hyg 2007.

    2. Bedell K, Buchaklian A, Perlman S. Efficacy of an automated multi-emitter whole room UV-C disinfection system against Coronaviruses MHV and MERS-CoV. Infect Control Hosp Epidemiol 2016.

    3. Van Doremalen N, Morris DH, et al. Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1. Letter to the Editor. NEJM 2020.
    CONFLICT OF INTEREST: None Reported
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    Oncology Nursing Society Interim Guidelines
    Lisa Kennedy Sheldon, PhD, ANP-BC, AOCNP, FAAN | Oncology Nursing Society
    The Oncology Nursing Society (ONS) supports full protection of healthcare workers handling drugs for cancer treatment that the National Institute for Occupational Safety and Health (NIOSH) has deemed hazardous, but nurses in clinical settings are facing difficult choices if recommended PPE supplies are not available. In addition, they are making choices regarding the protection of themselves and their patients from potential COVID-19 infection and use of PPE for safe handling of hazardous cancer drugs.

    ONS supports recommendations that the first priority when allocating PPE supplies is maintaining the protection of patients and healthcare providers from COVID-19 infection. For
    care of patients with COVID-positive infections, follow the Centers for Disease Control and Prevention guidelines for prevention of infection and optimizing use of PPE.

    Here is the link to the ONS Interim Guidelines: https://www.ons.org/covid-19-interim-guidelines
    CONFLICT OF INTEREST: None Reported
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    Heat Inactivated or Modified PPE
    Hong Luo, MD | Central South University
    Song et al [1] provided a simple method for heat inactivation of virus on the surface of personal protective equipment like medical masks  without damaging the filtration function of the treated masks by using a hair dryer to heat for 30min. This method can be easily used by community people. However, it is not suitable for people who were in close contact with patients such as medical staffs and laboratory technicians to use this method.

    Modified PPE has also been created by many clinicians. For example, image film and other plastic sheets that are available in the hospital could
    be modified into a face shield.

    It is important that medical staff treat patients in hospitals, but everyone in society can contribute in an effort to help address the COVID-19 pandemic by canceling gathering activity and decreasing unnecessary travel, which could help to limit the scale of epidemic thus relieve the current shortage of medical resources.

    Referrence

    [1] Wuhui Song, Pan Bin, Haidong Kan, et al. Evaluation of heat inactivation of virus contamination on medical mask [J]. Journal of microbes and infection. 2020, 15(1): 26-36. DOI:10.3969/j.issn.1673-6184.2020.01.006.
    CONFLICT OF INTEREST: None Reported
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    Home-Made Simple Face Shield
    Zhenhuan Cao, PhD | Beijing Youan Hospital, Capital Medical University
    During the outbreak of COVID-19, protective face shields were in short supply in Chinese hospitals. We made our own supplies at home using a clear film cover (A4), double-sided tape (3cm wide), elastic tape (3cm wide) and sponges (3cm thick). The instructions: the double-sided tape sticks on the top of the film cover, then sponges stick to the double-sided tape, finally use a stapler to fasten the elastic tape to the ends of the sponge. This homemade protective face shield may be simple and ugly, but it is very practical. The process is easy and takes two minutes.

    See
    https://new.qq.com/omn/20200129/20200129A0EUOB00.html (use Google Translate as needed) for illustrated details
    CONFLICT OF INTEREST: None Reported
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    Nasal PPE
    Beverly Tucker Woodson, Professor | Medical College Wisconsin, Milwaukee Wi, USA
    I agree with Dr Cherian from Singapore about taking a different approach. Let’s do better at attacking the virus at the critical chain of transmission of hands to face. Data suggests this is particularly important to the nose. I propose inexpensive, immediately and widely available nasal PPE for public use that provides both a physical barrier and micro- and possibly ultrafiltration of droplets and particles: an adhesive bandage (or Band-Aid). Carefully trim the central outer adhesive off the pad (which is often a high density melt woven fabric). Center the pad over the nostrils and apply. If it does not seal 360 degrees, then add the adhesive strips from another bandage to finish the seal. Trendsetters can add color (purple is my wife’s favorite). When moist or soiled, replace as needed.

    COVID-19 is transmitted via two methods 1) droplet/aerosol and 2) physical contact. Environment and physical contact may be a greater source than direct airborne transmission (1).  Surface contamination is an important component of SARS/MERS coronavirus transmission (2).  Droplet dispersion and infection is a major risk for individuals/healthcare workers within 1m especially with aerosol exposure but transmission is not uniform at oral, ocular, and nasal sites. Nasal transmission may predominate. For these reasons, a nasal PPE could reduce transmission

    REFERENCES

    1 Ong SWX, Tan YK, Chia PY, et al. Air, Surface Environmental, and Personal Protective Equipment Contamination by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) From a Symptomatic Patient. JAMA. Published online March 04, 2020. jama.2020.3227
    2 Otter JA, et al Transmission of SARS and MERS coronaviruses and influenza virus in healthcare settings: the possible role of dry surface contamination. J Hosp Infect. 2016;92:235-50. PMID: 26597631.
    CONFLICT OF INTEREST: None Reported
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    Alternative Materials for PPE
    Debra Walters, MPA (Env), BS (MT; ASCP) | Indiana University Health, Dept of Pathology & Laboratory Medicine, Retired; Specialist in Blood Bank (SBB); Specialist in Laboratory Safety (SLS, ASCP).
    One possible source of alternative material for face masks are lab coats that are used for PPE in labs. These are generally used over the course of a week (disposed of when soiled or at the end of work week).

    Another possible alternative are spill containment pads (absorbs spills; used to line buckets. pans. shelves). These generally have a plastic side and an absorbant side.

    Either one could be cut into the shape of a surgical mask with lengths of the material cut to use as tiebacks. Strings attached separately could be used too. These make
    shift masks will need to be modified with a hose or straws to allow the user to breathe. Tape could be used to hold these in place.

    These alternatives wouldn’t be tested for the size of particles that it can stop; however, the way it is made and their original, intended use makes them better alternatives than regular cloth, towels, or paper. And of course, breathing would be important for the users.

    Not glamorous but perhaps serviceable until normal product is received.
    CONFLICT OF INTEREST: None Reported
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    Clean Room PPE
    Robert Kraus, Ph.D. | Los Alamos National Laboratory, retired
    With many clean rooms in shut-down mode, perhaps the owners/operators can provide (through loan or gift) PPE that is useful. In fact, some clean room PPE is acquired from medical supply sources. I am aware of one clean room operator, while not shutting down, has made excess stock available to health care providers at no cost. This is exemplary of people reaching out to help our health care professionals who are critical to the recovery of our populace and nation.
    CONFLICT OF INTEREST: None Reported
    Constructing PPE with Materials More Likely to Be Well Supplied
    Lawrence Ong, MD, MEng | California Anesthesia Associates/Long Beach Memorial Medical Center
    We anticipate a fairly rapid depletion of our N95 mask and PAPR supply, and have developed a makeshift PAPR using core supplies that we think may remain readily available: a nasal cannula, a transparent plastic bag extending down the torso, and a large rubber band to create a comfortable seal around the neck. By connecting to 10-15 liters per minute of oxygen, we are able to maintain a breathable environment within the bag with measured CO2 remaining at a stable 10-15 mmHg. This solution presents a backup PPE plan for us in the event that we exhaust our current supply of N95 masks and PAPRs.
    CONFLICT OF INTEREST: None Reported
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    Balaclavas and Being Creative
    Isabella Baird, MD | Universidad Católica Santiago de Guayaquil
    N95 respirator masks can be used for 24 hours with multiple patients if worn with a balaclava over it. This balaclava can be disinfected like the rest of the scrubs and you don’t have to throw them away and can reuse them; one balaclava for each patient. If you don’t like the idea of balaclava then another option to cover the N95 mask is a full plastic face protector and you can disinfect the plastic face protector every time before visiting a new patient (because it’s plastic can be reused several times). No need of throwing the N95 mask (at least within 24 hours) if this is covered.

    For disposable medical gowns, reuse them by hanging them outside the patients' room and pasting your name on it so every person that sees that patient should do the same and reuse those gowns every time they see the patient instead of throwing them.

    Try to use fabric protective gowns, shoes covers that can be washed, disinfected and then reused several days. (But for this you will need time to get as many fabric protective gowns as possible).

    This will help not only the healthcare workers but the environment.
    CONFLICT OF INTEREST: None Reported
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    Re-usable Respirators
    Dag Olav Dahle, MD PhD | Oslo University Hospital
    Re-usable respirators with exchangeable P3 filter cartridges are used for construction workers. The filters are intended for multiple use and not exchanged until clotted by dust. Most of these filters are also effective against liquid aerosols, though there is little specific data regarding containment of bacteria and virus. This should be tested. Extra protection against droplets may be achieved by strapping a surgical mask over the P3 filter. Regarding re-use, some kind of sterilization is probably necessary. The face mask itself may be personal and cleaned with soap-and-water, ethanol and/or chlorine as per CDC recommendation and technical specs of the mask. Sterilization of the filter cartridges may be envisioned by for instance short-time heat treatment: the SARS-1 virus was reported to be inactivated after 90 minutes at 56 degrees Celsius (133 degrees Farenheit). Heat stability data for SARS-CoV-2 is soon expected.

    Others in this discussion have argued for re-use of the filtering facepiece masks (N95/FFP3) after for instance UV-ray sterilization. In such masks the expiration directly flows to the filtering parts (the mask itself), and condensation may limit re-use. For industrial masks, the P3 filter cartridges are protected from expiration by vents directing expiration directly out of the mask.

    Another option for sterilization would be gamma ray irradiation, akin to sterilization of spice. Again, it would be necessary to test the efficiency of viral inactivation and the stability of the filters under such conditions.
    CONFLICT OF INTEREST: None Reported
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    Compact Ozone Generator
    William Tejeiro, MD BC-HME USCG Lant-E | Orthopedic surgeon
    Consider cleaning your worn N95 masks in a resealable plastic bag connected to a hose attached to an ozone generating device such is used for cleaning CPAP masks. 10 minutes processing time will kill all pathogens. It's a dry process that won’t affect the fabric integrity and can be scaled up with a larger ozone generator or best if scaled to each individual provider for personal use and cleanliness.

    These devices can be purchased online and use standard CPAP hose connector. Use a ziplock bag to put your mask in. Many of the devices are pocket size and
    are portable with rechargeable batteries.
    CONFLICT OF INTEREST: None Reported
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    Suits and More
    Charles Weddington, MD | University of Maryland Medical Center
    1. One suit: all covid-19 patients on covid-only units, which are airlocked/negative pressure if possible. Providers interacting directly with covid+ pts put on one BSL-3 equivalent suit at the start of their shift, and do not change any suit element between patients unless visibly soiled, in which case they spray/wipe down with effective surface cleansers if possible, rather than changing suits. Repeatedly changing masks, gloves, faceshields is a huge waste of time and materials. This way you put one 1 set of PPE and break the barrier only to eat/drink/toilet/go home. Suits get some cleaning/sterilization method overnight and are ready to go the next day until they break down, which will happen. It's not about being perfect, it's about doing the best you can.

    2. IV pumps in hallways just outside doors to pt rooms: RNs can hang meds and adjust pumps without having to enter room, cutting number of trips into a room significantly. A nurse posted photos of this in action on a covid-19 healthcare social media thread and it is genius.

    3. Reduce people in room to a minimum: obvious, but rounding teams reduce the number entering rooms, no visitors except for births and deaths, proactive medical decision making with physician declarations of DNR for pts unlikely to survive arrest so as to avoid packed code situations.

    4. Stop contact precautions for other categories of patients in non-covid areas such as MRSA or VRE.
    CONFLICT OF INTEREST: None Reported
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    Alcohol-contained Spray
    Chao-Min Cheng, Ph. D. | Institute of Biomedical Engineering, National Tsing Hua University, Taiwan
    60-75% alcohol spray could be used for personal protection and equipment, operated either manually or automatically. Alternatively, hypochlorous acid could be used. Three formulations regarding alcohol-contained spray are below described.

    1) Ethanol Antiseptic 80% Solution
    2) Isopropyl Alcohol Antiseptic 75% Solution
    3) Isopropyl Alcohol Antiseptic 60% Solution
    CONFLICT OF INTEREST: None Reported
    UV Disinfection
    Denise Crute, MD, MBHI | Rockford Pain Management
    Although inefficient, tanning beds from closed salons, spas, and gyms might be deployed to UV-disinfect PPE, expanding opportunities for reuse. UV-A light emitted by the beds should still work, but would require longer exposure times than UV-C in conventional units. Hospitals can also commandeer many toy and water UV-C disinfection units for smaller items. The virology literature also explores use of sunlight for disinfection.
    CONFLICT OF INTEREST: None Reported
    Addendum on Snorkel Masks
    Anh L Tran, BSN | Brigham and Women's Hospital
    Thank you Dr. Fabricio Webber for the additional idea!

    I would also like to add that in the meantime, while we figure out how to 3D print the p100 filter, healthcare workers could use clean technique to cut a piece of the HEPA filter or N95 mask (both have a pore size of 0.3 micron) and cover the snorkel area on the full-face snorkel mask, securing it with tape or glue. This would add the needed airborne protection to the snorkel mask. We also need coordination among healthcare workers to ensure that we maximize the use of all
    the surface area of these HEPA and N95 to fit the snorkel area of as many masks as possible.
    CONFLICT OF INTEREST: None Reported
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    Taping classic surgical masks
    Jacquelyn Paetzold, DO | University of Texas Health Science Center at San Antonio
    According to a 2000 article (1), taping a classic surgical mask to create a seal improves its protective factor by nearly double for each of five volunteers evaluated. Perhaps taping surgical masks to create a seal along with other modalities could be an option when N95 masks are not available.

    REFERENCE

    1. Journal of the American Biological Safety Association, 5(1) pp. 12-18 © ABSA 2000
    COMPARISON OF PROTECTION FACTORS FOR SELECTED MEDICAL, INDUSTRIAL AND MILITARY MASKS. Bill Kournikakis, R. Kent Harding, J. R. A. Tremblay, and Maureen Simpson. 109135050000500105.pdf
    CONFLICT OF INTEREST: None Reported
    Decontamination and Reuse of N95 Respirators
    Brian Heimbuch | Engineering Science Division (ESD) of Applied Research Associates
    Over the past decade there has been research completed on the reuse of N95 respirators to prepare for this type of event. The research points to a few methods that inactivate influenza virus and have limited impact on performance of the respirator. However, the research is usually limited to a few models of respirators and limited cycles of decontamination. Most studies performed 3 cycles but some were up to 20 cycles. I providethe relevant citations below. I also provide a few notes on methods people may be considering:

    UV Light – We have performed extensive research on UV light
    disinfection of filtering facepiece respirators (FFRs). It does show promise, but the dose applied must be quantified to ensure it is adequate for inactivation. We also have data to show this would be effective for SARS and MERS. We found the UV light leaves a burnt smell on the FFR. UV light is also harmful so you need to be careful not to expose workers.

    Bleach – Wiping the FFRs with bleach had little impact on the performance of the respirator. Only three disinfection cycles were completed. Residual bleach may be a concern for dermatitis.

    Isopropyl Alcohol – It is known that alcohols degrade the filtration performance of N95 FFRs. This was demonstrated in a submersion method, but you need to be careful even if you are spraying the alcohol on the respirators.

    Moist Heat Inactivation – Respirators heated to 60C/80% humidity (place respirators on a rack in a water bath in a sealed pan) for 30 minutes inactivated influenza virus. After three treatments little decay in filtration performance was identified. However, some FFRs had nose pad separations.

    Microwave Generated Steam – This is a quick treatment. Essentially the respirator is placed on reservoir with a defined depth and volume of water. The microwave generates steam that was shown to inactivate the virus. While these seems simple, there are many considerations. Also, not all respirators will work due to arcing. If you want to try this please obtain the research articles that define the procedure.

    Large scale methods like vaporized hydrogen peroxide and ethylene oxide also had very little decay on performance of the respirator.

    We want to help so please reach out with your questions.

    REFERENCES

    Heimbuch BK, et al., A Pandemic Influenza Preparedness Study: Use of Energetic Methods to Decontaminate Filtering Facepiece Respirators Contaminated with H1N1 Aerosols and Droplets , AJIC, 2010;38(1):3-8

    Heimbuch BK, et al., Cleaning of Filtering Facepiece Respirators Contaminated with Mucin and Staphylococcus aureus. AJIC, 2014;42(3):265-270

    Bergman MS et al., , Evaluation of Multiple (3-Cycle) Decontamination Processing for Filtering Facepiece Respirators, JEFF, 2010; 5(4):34-41

    ASTM E3135-18: Standard Practice for Determining Antimicrobial Efficacy of Ultraviolet Germicidal Irradiation Against Microorganisms on Carriers with Simulated Soil.

    Mills D. et al., Ultraviolet Germicidal Irradiation of Influenza-Contaminated N95 Filtering Facepiece Respirators, AJIC 2018 Jul;46(7):e49-e55

    Salter WB et al., Analysis of Residual Chemicals on Filtering Facepiece Respirators after Decontamination. JEOH, 2010;7(8):437–445

    Bergman et al., Impact of Three Cycles of Decontamination Treatments on Filtering Facepiece Respirator Fit, JISRP, 2011;28(1):48-59

    Viscusi et al., Evaluation of Five Decontamination Methods for Filtering Facepiece Respirators, Ann. Occup Hyg, 2009;53(8):815-827

    Viscusi et al., Effect of Decontamination on Filtration Efficiency of Two Filtering Facepiece Respirator Models, JISRP, 2007;24:93-106
    CONFLICT OF INTEREST: None Reported
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    Single-use Mask from Readily Available Materials
    Scott N Schiffres, PhD, Mech. Engineering | Binghamton University
    I've been thinking about how to make disposable masks for patients and caretakers in mass quantities. I've restricted my material-set to commonly available and mass-produced materials.

    My idea is to use coffee filters with a seal to the face made with a lightly adhesive tape (eg painters or masking tape) or adhesive spray around the border. The coffee filter is not hydrophobic, so it wouldn't work for extended periods, but may be good for brief periods.

    I did a qualitative test of the filter with a nebulized sugar solution. A local hospital
    will do quantitative testing later today. I made this video on the masks and my preliminary testing: https://youtu.be/qIiG56I_Xbc

    As a disclaimer, my research area is not normally masks, but I'm trying to help.
    CONFLICT OF INTEREST: None Reported
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    Reusable Elastomeric Respirators' Role in Healthcare
    Stella Hines, MD, MSPH | University of Maryland School of Medicine
    The National Academies of Sciences, Engineering and Medicine (NASEM) recommends that reusable elastomeric respirators be considered for routine and surge use in healthcare respiratory protection programs (RPP), provided cleaning and disinfection protocols are specified. Additionally, the CDC recommends inclusion of reusable elastomeric respirators as one strategy to preserve N95 respirators (N95) during periods of shortage in healthcare settings.

    Reusable elastomeric respirators, while infrequently used in healthcare, are in common use in general industry. These respirators are approved by the National Institute for Occupational Safety and Health (NIOSH), just like N95s. Similarly, elastomeric respirators are tight-fitting, negative pressure respirators and
    require a fit-test. They are made by various manufacturers and come in different sizes. They provide the same level of protection according to OSHA based on an Assigned Protection Factor of 10. Some experts believe that the level of protection afforded by these respirators may actually be higher given the greater reliability of the seal between the mask and the face. Elastomeric respirator facemasks connect to filters. Plastic cartridge-covered filters can be used and not replaced unless they either become soiled or noticeably hard to breathe through. These respirators can be worn with eye protection or face shields.

    Elastomeric respirators can be cleaned and disinfected repeatedly. Cleaning involves removal of soiling agents like facial oils, while disinfection involves removal of microbial agents. Evidence-based protocols for both exist. Disinfection can be accomplished by use of standard EPA-registered hospital disinfectant wipes with claims against the appropriate microbial agent (such as SARS-CoV-2), while cleaning is accomplished by removal of the cartridge filters and submersion in soapy water.

    Respirators may be assigned to individuals or could be shared, provided that thorough cleaning and disinfection has occurred. Users must know their facemask size and adjust the straps to achieve proper fit. Before each use, users perform seal checks to assure the integrity of the seal, which is taught during training. In a crisis situation in which fit-testing may be untenable, assurance of seal by performing seal checks may provide assurance.

    The University of Maryland Medical Center and Faculty Physicians Inc. practices have utilized elastomeric respirators as components of their OSHA-compliant respiratory protection programs since 2009’s H1N1 influenza pandemic, when N95 respirators became scarce. They are the primary form of respiratory protection for FPI employees performing clinical duties and part of the COVID-19 response for certain UMMC healthcare workers. Both sites have used the 3M 7500 series respirator with P100 cartridge filters.

    Healthcare worker user acceptance, storage, cleaning and disinfection practices of these respirators during non-pandemic use has been studied and published by Hines et al. in previous NIOSH-supported research.
    CONFLICT OF INTEREST: My University receives research funding from a respirator manufacturer, CleanSpace Technology, to study use of reusable respirators in healthcare, an investigator-initiated project.
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    Reusable 3M respirators & P100 cartridges
    S Udwin, LLB | Lawyer (Government policy and biomedical research background)
    After detailed research, I believe 3M 7500 series half-face respirators (worn with protective eye-wear) are a much better choice than disposable N95 masks, and that their manufacture should be a matter of urgent government priority, public-private-health organization partnership, and societal effort.

    3M explains that their reusable respirators, when equipped with N95 or P100 filters, are equivalent or superior to N95 masks for healthcare workers, per its detailed guidance on its coronavirus resources webpage, "Possible Alternatives to Surgical N95 Respirators (in the US): Healthcare". The N-95 and P-100 standards have for decades been regulated by US federal law, and
    it seems to me that 3M is the leading manufacturer working with the CDC and WHO.

    This respirator is superior to a disposable N-95 mask because it:

    1) Contains a silicone seal around the nose and mouth, making it likelier to be effective;
    2) Can be sanitised and reused again indefinitely until it starts breaking down; and
    3) Is easier to breathe through than previous models, as it is designed to cut down breathing resistance that builds up in an N95 mask. The filters that can be attached to the masks with can also be used for months before they need to be replaced.

    As 3M states on its website, demand will outstrip supply for the upcoming months, despite their efforts to ramp up production. Given this, sales should be made only to hospitals, aged care facilities and caregivers at this time: and be made directly from the manufacturer. Governments, in partnership with the health and scientific community and the public, should ensure manufacturers have all they need to produce them in every locality they are needed, from raw materials to personnel recruited from the public.

    If the availability of raw materials is a bottleneck, the public can donate materials (such as silicone and plastics) that can be repurposed with the help of recyclers. For private persons in possession of extra respirators and filters, an Internet-based program should be set up to facilitate their lending or donation to local hospitals.

    Points to note:
    * These respirators protect only the wearer. The air breathed in is filtered; the air breathed out is not.
    * The filters capture viruses despite their nanoscopic size, because viruses almost always travel in much larger respiratory droplets.
    * They can be easily removed; which is important as those unused to wearing them may find them difficult to wear without a break.
    * For more information, please contact 3M, which has been very responsive in this crisis.
    CONFLICT OF INTEREST: None Reported
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    Central Command for Medical Supplies
    Ian Joffe, MD, FACC | Penn Presbyterian Medical Center
    A central command should be established for responding to the need for medical supplies, including ventilators, respirators, masks, gowns, gloves etc. The COVID-19 outbreak has regional and local variations at any given time. Some hospitals, even close to a regional outbreak, may not be seeing the volume of patients that another hospital is. The Johns Hopkins website tracks cases daily. The central command would partially be a repository for supplies, but would also move supplies between hospitals where needed most. At this time it appears that each hospital is acting independently, but a central command would be in contact with each hospital on a daily basis, assessing their needs and responding, either with supplies from a central repository and/or moving supplies from one hospital to another.
    CONFLICT OF INTEREST: None Reported
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    Population of Massachusetts Mobilize to Rapidly Produce Cloth Masks
    Patricia Roberts |
    A family of healthcare professionals in Massachusetts, sparked by the critical shortage of masks, have quickly started an initiative to engage the expertise of the local population to produce cloth masks for area hospitals. We are increasingly involving local and national businesses as well as over 3000 volunteers to fill this need. The group is called Masks 4 Massachusetts.
    CONFLICT OF INTEREST: None Reported
    Switching to A Conservative Mode
    Meera Mohan, MD MS | University of Arkansas for Medical Science
    While the world is facing the unprecedented pandemic of our lifetime, we need to switch to a conservative mode to help our front line HCW.
    # We have initiated a daily screening questionnaire for all employees. At this hour of utmost need, we should have all non-essential administrative and non-clinical staff work from home; in that way the number needed to be screened and the resources used can be put to better use.
    # Drive-through COVID19 screening stations will help our already strained urgent care or emergency room. Non-essential staff could be used to help drive-through, online or
    telephone triaging.
    # Closed ICU should be strictly implemented to limit number of personnel encountering the sick and thus conserve PPE resources.
    # UV irradiation could be used to help us re-use PPE safely. Cloth mask, although a less effective alternative is an option and perhaps reach out to our community to help make them.
    # Encourage all research labs, dental, dermatology, ophthalmology, veterinary clinic etc. to donate their PPE to the pool for use.
    # Teaching rounds with fellows and residents should be strongly discouraged to minimize mass contact with a possible patient. We should think of smart ways to create "a reserve pool of physicians" in the hour of crisis. We should mandate all elective clinics and procedures to be cancelled, to not only minimize exposure but re purpose the staff to the single most important cause of fighting “the COVID19”.
    CONFLICT OF INTEREST: None Reported
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    Homemade Wool Masks from Women's-March-type Hat Makers
    Gary Cordingley, MD, PhD | Ohio University Heritage College of Osteopathic Medicine
    My niece sent my wife and me some lovely thick handmade masks made from wool that included malleable copper strips to shape around the nose and black elastic bands to stretch around the ears. They were made of different colors to enable tracking of which mask was which (e.g. for knowing which one belonged to whom or was in a rotation to recycle). I think they will be quite effective. I will be happy to send a picture of them if a mechanism for attaching jpgs is enabled.

    This brought to mind the yearly "Women's March" protests starting the
    day after the presidential inauguration of 2017. Participating marchers were sent plans to make their pink "pussy hats," but not all protesters were good at knitting or sewing, so a limited cottage industry of producers came into being who sold their masks over Etsy and other such internet exchanges. Why not engage all those capable individuals who have to stay at home but who could earn money by producing these?
    CONFLICT OF INTEREST: None Reported
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    Point-of-Care RNA-based Detection Device for COVID-19
    Chao-Min cheng, PhD | Institute of Biomedical Engineering, National Tsing Hua University
    Because the standard clinical RT-PCR test is unlikely to meet rising test demand, there is a critical need for the development of alternative approaches for home-based point-of-care (POC) testing. More widespread accurate identification of infected vs non-infected patients could save PPE.

    Here we suggest a potential RNA-based POC diagnostic device for detecting COVID-19 that combines both a paper-based diagnostic device and loop-mediated isothermal amplication (LAM) technology. We have previously described this technique (1). 

    The concept for this tool is derived from previous research on paper-based nucleic acid detection employing RT-LAMP assay amplification. Paper-based diagnostic devices have been widely applied
    for a variety of biochemical assays due to their low cost, ease of use, and speed. They have been employed to test a range of sample sources such as blood, urine, tear, and vaginal fluid, and could be easily adapted to accept nasal swab samples for viral detection. The potential rapid and easy-to-use paper-based LAMP device for COVID-19 outbreak could be used in combination with a smartphone application to facilitate test results recording and sharing. Using this tool, a home-quarantined individual could easily self-collect a nasal swab sample; perform LAMP technology; and observe a visible, colorimetric test result that could then be recorded and shared with clinicians or healthcare professionals via the internet.

    Reference

    1. Diagnostics, 10, 165, 2020, doi:10.3390/diagnostics10030165

    Idea from Chao-Min Cheng (Institute of Biomedical Engineering, National Tsing Hua University, Taiwan) and Ching-Fen Shen (Department of Pediatrics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Taiwan)
    CONFLICT OF INTEREST: None Reported
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    Face Shields from Clear A4 Page
    Theodore Murphy, MB BCh BAO NUI MRCPI MSc | St Vincent's University Hospital Dublin
    Face Shields are a key component of personal protective equipment, yet in increasingly short demand.

    These shields can be made in under 1 minute, and provide a large area of cover although slightly less than the standard.

    This can be made using standard equipment available at any large stationary store.

    1. Use a clear A4 Acetate Sheet (240 microns), though any clear relatively firm shield will do (eg
    https://www.amazon.co.uk/Acetate-Sheet-A4-240microns-10/dp/B0027IXRNA)

    2. Round off the edges to allow a smooth finish to stop it catching on garments.

    3. Using a hole puncher punch
    two holes on the top two corners - this has to be lined up carefully to the foam as it affects the angle that the shield sits on the face.

    4. Use 2x snap rivets (2.5mm) to secure the elastic to the plastic shield (https://www.dwssupplies.ie/products/snap-studs)

    5. Through a foam factory or elsewhere get soft foam made to measurements in these files: 

    https://www.dropbox.com/s/hs04cptayppx1xg/Foam%20dimensions.png?dl=0
    https://www.dropbox.com/s/kjd8ud7fihwor6c/Facesheild%201.pptx?dl=0

    You can choose to leave out the middle rectangle to allow for ventilation.

    6. Attach a flat elastic band measuring about 30cm long (depends on the elasticity) and 2.5 cm wide (distributes the pressure better) to pre-made holes.

    7. Assemble as you see fit.

    Although not HPRA/FDA/ MHRA approved - they may be better than nothing in under resourced countries/hospitals!

    Hope this helps the fight against COVID-19.
    CONFLICT OF INTEREST: None Reported
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    Placement of IV pumps and ventilator monitors outisidw the isolation rooms to minimize PPE use and staff exposure
    Natalia Solenkova, Intensivist | Memorial Healthcare System
    The amount of available PPE depends not only on supply, but also on careful minimized use. While supply is managed by hospital administration, the use of PPE by healthcare workers can be optimized by bedside personnel. The intensivists of Memorial Healthcare System (Hollywood, FL) and critical care nurse practitioners placed ventilator monitors and IV pumps outside of isolation rooms. 

    - For the IV extension the following supplies were utilized:

    One BD Alaris Pump Infusion Set (REF 2420-0007)
    Three Clearlink System Extension Set (REF 2C8612)
    Alaris Standard Pump.

    Initial set up was done outside the isolation room: /> -Spike and prime IVF/Medication to primary infusion tubing
    -Link extension sets serially and then prime to completion
    -Repeat steps as necessary to provide sufficient separate and/or secondary infusions
    -Label/date all tubing at connection points and where tubing will be external to the door

    Setup was completed inside the isolation room:
    -Ensure labels are visible from outside
    -Ensure that the door closes completely with tubing secured
    -May be secured with tube holders, tape, or any device available
    -Verify all tubing has been completely primed before connection to intravenous access sites

    General Guidance:
    -Suggest all cardiac drips/pressors are linked together for infusion
    -Intermittent drips (ie. antibiotics, antiepileptics, et al.) should be hung strictly outside the room via secondary setups
    -Consider having redundant pre-primed maintenance fluids connected to open/free central venous access port to enable quick initiation of new infusions

    - The ventilator monitor extension used

    A Servo-I Ventilator
    Standard circuit tubing/length
    Ventilator Monitor Stand (alternative device can be used).

    Initial setup was performed outside of the isolation room and included the following steps:

    -Ensure monitor detaches from its base and can be placed on monitor stand and operates properly
    -Complete ventilator check

    The final setup was completed inside the isolation room:
    -Place ventilator situated at the foot of the bed to eliminate the need for additional circuit tubing
    -Connect patient to ventilator circuit as would normally done
    -Maintain one RT outside to manage the monitor and evaluate the system
    -Maintain one RT inside to manage the patient to ensure circuit is functioning properly

    General Guidance:
    -Ensure that isolation door closes completely without disrupting the monitor cable
    -Complete full ventilator check prior to arrival of patient and complete setup both outside and inside the isolation room prior to intubation if possible
    -Monitors are fragile and must be protected from damage

    Additional images and videos can be provided. This set up is constantly being optimized. All questions can be answered at kevin.c.tipton@gmail.com.
    CONFLICT OF INTEREST: None Reported
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    Staffing COVID wards
    Robert Lennon, MD, JD | Pennsylvania State College of Medicine
    Dr. Wexler's comment recommending staffing COVID wards with naturally immune staff to obviate the need for PPE is an excellent expansion of Dr. Weddington's COVID-only ward comment. Communities without significant COVID infection may lack sufficient naturally immune staff to adequately resource a COVID ward in this fashion. Two solutions are:

    1) Consider staffing on a regional vice local scale and allow 1:1 staff transfers so that areas with more COVID-immune staff than needed can "trade" for equivalent levels of care with areas without sufficient COVID-immune staff.

    2) More radically, seek a cadre of young, healthy healthcare workers from
    areas with minimal COVID to voluntarily seek exposure to gain immunity. While there are obvious ethical concerns to address with this approach, intentional infection is already being implemented for vaccine trials. Further, infection rates for young, healthy healthcare workers is likely to be high - over 20% being reported in one hospital in China (1). Controlling the timing of infection in healthcare workers may be used to help this staffing dilemma, much like controlling the timing of infection in the general population is currently being used to decrease maximum demand on healthcare facilities.

    REFERENCE

    1. Gan N, Thomas N, Culver D. CNN. Over 1,700 frontline medics infected with coronavirus in China, presenting new crisis for the government. 2020 [cited 2020 Mar 2]. https://edition.cnn.com/2020/02/13/asia/coronavirus-health-care-workers-infected-intl-hnk/index.htmlExternal Link
    CONFLICT OF INTEREST: None Reported
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    Getting PPE from Academia/industry to Hospitals
    Zahra Khan, MS AeroAstro | None
    As an aerospace engineer from SoCal I am working on a solution to match donations of PPE from academic and industry labs to hospitals in need. We are currently doing intake for donor labs and hospitals.

    Collaborations are welcome. Ping us through our website: ppelink.org

    I can personally be reached at www.linkedin.com/in/zeikpublic
    CONFLICT OF INTEREST: None Reported
    DIY Face Masks and Face Shields
    Jennifer Su, BS | Medical College of Georgia at Augusta University
    Due to the lack of PPE, the CDC now recommends homemade face masks in combination with face shields as last resort for treating COVID-19 patients.

    In addition to the previous comment from Paul Bergl, M.D. about organizing homesewn face masks, the community can also make their own face shields with cheap, readily available supplies from the arts & crafts store. The University of Wisconsin-Madison has shared their open-sourced design: https://making.engr.wisc.edu/shield/

    Hospitals are already having physicians and staff reuse proper surgical masks and N95s. These homemade face masks may be used over proper N95 masks as an additional barrier
    to try to preserve them longer. Because of how simple the masks are to make, healthcare providers may use multiple homemade masks within a single shift. These homemade masks would have to be laundered at least daily.
    CONFLICT OF INTEREST: None Reported
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    Please remember to contact your state government
    Cynthia Sundahl, MA | Former Hospital Administrator/Government
    Any hospital or health care facility dealing with shortages shouldn't forget to contact their state officials.

    Every state public health department/office of emergency services/governor should have teams that are trying to coordinate solutions including requesting and distributing emergency supplies.

    It is crucial for states to know where the shortages are occurring so they can effectively direct resources.
    CONFLICT OF INTEREST: None Reported
    Elastomeric Masks
    Jeffrey Bruckel, MD, MPH | University of Rochester Medical Center, Interventional Cardiology
    Elastomeric masks are the real solution. These are widely used by a huge variety of industries, who have large stockpiles of equipment. The P100 filter is more protective than the N95 standard used in healthcare. The filter disks can be re-used for up to six months, and sterilized in UV. The masks themselves can be bleached for 10mins for sterilization.

    There should be a national call for all industries (construction, chemical, etc) to immediately donate their supplies to local hospitals and medical centers.
    CONFLICT OF INTEREST: None Reported
    Plastic bottles recycled into face protective devices
    Michel Gagner, MD | Westmount Square Surgical Center
    Palawan eco-artist JC Enon has transformed plastic bottles into personal protective equipment (PPE) face shields for healthcare workers in the battle against COVID-19 in the Philippines (1). You need clean transparent 1.5 or 1.75 liter plastic bottles, a pair of scissors, double-sided tape, garter, puncher and thermal foam. The face shield is made by cutting the end part of the bottle, then the bottle into half, trim the sharp sides and punch both sides, double-sided tape on the glittery part of the thermal foam and then tape it into the bottle (for your forehead). Finally, tie garter on both sides.

    REFERENCE

    1. https://www.goodnewspilipinas.com/palawan-eco-artist-jc-enon-transforms-plastic-bottles-into-face-shields-for-healthcare-workers/
    CONFLICT OF INTEREST: None Reported
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    Implementation of PPE resources in Taiwan
    Hui-Ju Tsai, MPH, PhD | National Health Research Institutes
    We would like to share our experiences in handling potential crisis of PPE shortage in Taiwan at the governmental, community, and personal levels, respectively.

    # Governmental: The Central Epidemic Command Center (CECC) in Taiwan has played a role in using government funds for rapid PPE production; and controlling allocation of PPE resource, for example, surgical masks and N95 masks. CECC has set up priority to allocate quantity of surgical masks and avert PPE shortage in medical facilities.

    # Community: In Taiwan, there are nearly 6,500 National Health Insurance (NHI)-contracted pharmacy stores. Since the COVID-19 outbreak, each pharmacy store
    has been allotted 200 adult masks and 50 child masks per day. Pharmacists have provided professional services not only in distributing masks at a reasonable price but also in reducing worry and mitigatomg anxiety of residents. In addition, the Taiwan government has created an online real-time platform displaying the availability of masks and the address of pharmacy stores across Taiwan. The policies have largely diminished the crowd of people waiting for mask purchase.

    # Personal: Since the threat of the COVID-19 outbreak, Taiwan citizens have been restricted to purchase a limited number of masks, for example, two masks per week in early February, 2020 and three masks per week from early March, 2020 till now. People have to show his/her NHI ID card while purchasing masks. Alternatively, people in Taiwan have started using handmade fabric masks, which can be cleaned repetitively. Each fabric mask has a surgical mask in the inner layer to prolong use of the surgical mask.

    Deploying the above strategies can serve as a relief under the urgent situation of PPE shortage.

    Hui-Ju Tsai, MPH, PhD, Institute of Population Health Science, National Health Research Institutes, Taiwan
    Jiu-Yao Wang, MD, D.phil (Oxon), Center of Allergy and Clinical Immunology Research, National Cheng Kung University, Taiwan
    Chao-Min Cheng, PhD, Institute of Biomedical Engineering, National Tsing Hua University, Taiwan
    Wei-Chiao Chang D.Phil (Oxon), School of Pharmacy, Taipei Medical University, Taiwan
    Chih-Da Wu, PhD, Department of Geomatics, National Cheng Kung University, Taiwan
    CONFLICT OF INTEREST: None Reported
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    Remote Vital Signs System
    Todd Barnett, BSN, MBA | EarlySense
    The EarlySense system is being used in Israel at Sheba Medical Center to help protect staff and minimize contact with patients (1). The system uses a sensor that does not come in contact with the patient but continuously looks at vital signs and remotely displays them for clinicians to view. There are numerous benefits including the early detection of deterioration and the reduction of exposure of healthcare workers. Caregivers do not need to enter the room to take vital signs, thereby reducing the use of the limited PPE resources and limiting direct contact with patients. The system can be set up in acute care wards, post-acute facilities, temporary pop up hospitals or even sequestered hotel type structures.  

    REFERENCE
    1. https://www.earlysense.com/press_releases/earlysense-helps-sheba-medical-center-protect-staff-treating-patients-from-coronavirus-exposure-with-contact-free-continuous-monitoring/
    todd.barnett@earlysense.com
    CONFLICT OF INTEREST: Vice President for Government Affairs at EarlySense
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    Methylene Blue and Light
    Llew Keltner, M.D., Ph.D. | Columbia University
    First, thank you for your efforts in these troubled times, and all the best to you, your families, and your patients. The comments here are intended to assist with the re-use of PPE.

    My colleague Jim Chen, M.D., Ph.D., and I have been working with light activated drugs for 3 decades at Light Sciences Oncology, where we have completed a number of late stage trials in oncology and urology with light activated compounds. We have been aware for 20 years of the potential of methylene blue (MB) for destruction of pathogens when exposed to adequate light.
    MB has been used routinely in the EU for many years for plasma sterilization (Macopharma and others). In consultation with our colleague Dr. Tom Lendvay at Children’s Hospital in Seattle, we believe the following technique may work for sterilization of PPE:

    1. Secure MB from your hospital lab, local chemical/lab supply distributor, or a manufacturer (several links below).
    2. Make a sterile 1 micromolar solution of MB and place in sterile spray bottles. (Quick cost calculations indicate that MB cost should approximate $.02 per PPE treated.) If needed, consult with your lab for proper solution prep instructions.
    3. Find a room which can be kept in relatively sterile conditions with plenty of flat surfaces. An operating suite is best, but if not available, any room will suffice.
    4. If an operating suite, no room preparation is necessary. If not, get enough “warm” LED spotlights (nothing special, just the relatively high-wattage warm LED spotlights at Home Depot, Target, Costco) and rig them up so all of the PPE to be placed on the flat surfaces will be within 3 feet or less of the lights. Easiest way is to buy the “work light” units from Costco, Home Depot, or others, but any maintenance person should be able to get bulbs, sockets, extension cords, 2x4s, or other “hangers”. (Note: the critical absorption peak for MB is at 665 nm in the red, so the “warm” LEDs will work better, BUT fluorescent tubes, “cool” or “daylight” LEDs, incandescent lights will also work if necessary.)
    4. Lay the contaminated PPE out on the flat surfaces. Put the user-contact side UP for full exposure to the lights.
    5. Thoroughly spray all sides and all parts (include straps, attachments, etc) of the PPE with the MB solution.
    6. Turn the lights on and leave them on for about 8 hours. This is VERY likely huge “overkill”, but it is a traditional “shift” length, so more reliable. If the particular PPE has several user contact surfaces, then in sterile conditions turn the PPE and re-spray for full light exposure - half the time (4 hours) per side again is likely huge “overkill”.
    7. Remember to use sterile handling when picking up or re-packaging the sterilized PPEs. Remember that when the lights are turned off, the sterilization stops. The solution alone will NOT sterilize.

    The interaction of the light with MB produces singlet oxygen, an exceptionally powerful oxidizer, which destroys by cleavage biological structures, including nucleic acids, proteins, whole microbes, and human cells or tissue aggregates which are in very close proximity to molecules of MB. There is no available evidence that such low concentrations of MB and any residual MB which might be inhaled by the user have any pulmonary toxicity, nor is there available evidence of allergic reactions to very small concentrations of MB.

    Please contact me for additional information and references.
    CONFLICT OF INTEREST: None Reported
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    Baby Wipes in 70% alcohol or Bleach solution
    Thomas Sedlak, MD, PhD | Johns Hopkins, Department of Psychiatry and Behavioral Sciences
    Many popular antimicrobial cleaning wipes utilize benzalkonium chloride or other quaternary ammonium salts as a biocidal ingredient, although these have suboptimal inactivation against the coronaviruses (1). These products, or common baby wipes, can be soaked in 70% alcohol or diluted bleach solutions (0.1% hypochlorite) to improve decontamination of surfaces.  Clean work and living areas will reduce the strain and longevity of PPE. It has been reported that SARS-CoV-2 (COVID-19) can survive up to 72 hours on surfaces (1). Decontamination supplies have become periodically scarce.

    References

    1. Kampf G, Todt D, Pfaender S, Steinmann E. Persistence of coronaviruses
    on inanimate surfaces and their inactivation with biocidal agents. J Hosp Infect. 2020;104(3):246-251. doi:10.1016/j.jhin.2020.01.022
    2. van Doremalen N, Bushmaker T, Morris DH, et al. Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1. N Engl J Med. 2020. doi:10.1056/NEJMc2004973
    CONFLICT OF INTEREST: None Reported
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    Scour Your Hospital
    Pete Steinberg, MD | Beth Israel Deaconess Médical Center
    Obviously a surge of new supply is ultimately needed to solve this; however, existing supply must hold out till reinforcements arrive. Options to do this:

    1. Search high and low through all clinical areas and storage units. The sheer number of people finding N95’s from a random home Improvement project is staggering and can likely supply our system until resupplied. The same applies to hospitals.
    2. Search all nonclinical and research areas as well. The number of disposable OR device samples we have found over the years in academic offices is enormous — laser fibers and baskets eg
    (I’m a urologist). The resident’s office, the emeritus professor’s bookshelf, the OR nurses lounge. Supplies are lurking everywhere. Have a thorough look and you’ll be surprised.
    3. Rob from Peter to pay Paul. Take the supplies from units without PUI and leave them with a bare minimum of supplies.
    4. When procedures on non COVID patients must be done, have providers conserve gowns and masks, without disposing of them. In the OR, a mask should be able to last most of the day, as we all know from experience.
    CONFLICT OF INTEREST: None Reported
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    Telemedicine for Specialty Consultations
    John Christopher Trinidad, MD, MPH, FAAD | The Ohio State University
    Dermatologists are poised to utilize teledermatology to increase access to dermatologic care for hospitalized patients, shorten hospital stays for dermatologic conditions, reduce the risk of infection of patients, trainees and staff, and reduce the use of precious resources such as personal protective equipment (PPE) and medical supplies.

    We propose that dermatologists and other subspecialists in hospital settings initiate the utilization of telemedicine to treat and triage as many patients as possible. We have submitted a framework to JAMA Dermatology currently under review with a stepwise algorithm as a Special Commentary. In this communication we divide patients into three
    specific groups:

    1) Appropriate for telemedicine consult
    2) Standard dermatology consult requiring in person evaluation
    3) COVID-19 High risk dermatology consult requiring in person evaluation and PPE

    This algorithm has already been approved at our hospital system as well as many others. We hope that this algorithm can help to continue to provide dermatologic care for our hospitalized patients while limiting transmission of COVID-19 and utilization of precious resources such as PPE.

    Institutional limitations may include access to HIPAA-compliant photo-sharing, videoconferencing or electronic medical records. Additionally, as resources and medical staff become more limited, hospital-based dermatologists and trainees may be conscripted to other facets of disaster relief.

    Please feel to contact me and I would be happy to share our internal hospital guidelines and algorithm for institution of telemedicine consults for dermatology.


    John Trinidad, MD MPH 1

    Acknowledgements:
    Daniela Kroshinsky MD MPH 2, Benjamin H. Kaffenberger MD 1
    Nathan Rojek MD 3

    1 Division of Dermatology, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus, Ohio.
    2 Department of Dermatology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
    3 Department of Dermatology, University of California, Irvine, California
    CONFLICT OF INTEREST: None Reported
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    Follow the risk pyramid - 1) eliminate, 2)controls, 3) procedures, 4)PPE
    Liz Kamali, Chem Eng BS, Env Eng MS | EHS Professional / HAZMAT, Pharmaceutical Industry
    The risk or hazard control pyramid is structured as:
    1. Eliminate the hazard
    2. Use engineering controls
    3. Use administrative controls/procedures
    4. Use PPE.

    Here’s an application to COVID-19:

    #ELIMINATE RISK: Limit personnel or have patients avoid the hospital altogether with tele-medicine. or move COVID patients to isolated, heavily ventilation controlled mobile units with limited personnel requiring PPE 

    # ENGINEERING CONTROLS: Employ facilities/engineering/industrial hygiene to see if you can use increase the number of room air changes and HEPA filtration in rooms and utilize at source (eg elephant trunk ventilation like they use in active pharmaceutical ingredient
    or chemical settings). Also, deploy a strategy to clear rooms and decon more frequently with sealed room decons like ClO2 or another technology we can validate for killing COVID19 chlorine dioxide gas decontamination (1,2,3)

    #ADMIN CONTROLS/PROCEDURES: More procedures and training for medical staff on patient and medical personnel flow (the goal being to reduce contact with patients and staff and isolate the COVID19 footprint in medical settings like in reducing bioburden in aseptic/vaccine manufacturing). Limit residents and nurses in the room. Procedures are needed to get critical supply PPE procurement limited.

    #PPE. Develop standard disinfection of PPE protocol using current technologies (eg autoclave, sterilizer, irradiation, chemicals, Eto/ClO2 for COVID19 and most common hospital organisms)(4). Divert PPE from currently out-of-service labs or non-critical use (universities, dentists, pharma, clean rooms, vets). Create community PPE dropoffs using trained County/State HAZMAT (LEPC/SERC)-manned drive-thru drop off points or pick up and in every state and every community corner to collect any household use respirators (N95/purified air purifying respirator and cartridges, self contained breathing apparatus [scba]), tyvek, gowns,. list especially in need from construction, pharma, dentists, university labs, biotech, retired safety professionals, hazmat, lab professionals, mold asbestos contractor, anyone who ordered or used PPE. Decontaminate equipment or come up with strategy to decontaminate (eg irradiate, autoclave, whatever appropriate to demonstrate appropriate kill of organism). Set/follow decontamination standard for demonstrated kill of organisms(s). Train medical staff in more conservative scba or full facemask by hazmat or emergency services or diving instructors if that is the only way they can be protected and there are units available from emergency services or diving operations, or other more conservative full face masks

    REFERENCES

    1. Chlordysis https://www.clordisys.com/?gclid=Cj0KCQjw9tbzBRDVARIsAMBplx8Tbp5bLclPlaprYayrtB4U_ddP9m5z_lSPEzvPDGVG-XiHgAMPBpoaAggkEALw_wcB)
    2. https://www.aiha.org/education/elearning/ventilation-surface-disinfection-and-ppe-considerations-for-the-ip-and-ih
    3. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2843946/
    4. https://www.cdc.gov/infectioncontrol/guidelines/disinfection/sterilization/other-methods.html) https://www.epa.gov/sites/production/files/2018-01/documents/qc-13-09.pdf
    CONFLICT OF INTEREST: None Reported
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    Call On Aerospace Industry To Donate PPE
    Melissa Rowan, BS Aerospace Engineering | Former Aerospace Engineer
    In January, Boeing donated 250,000 respirators to China to combat the coronavirus (1).

    The aerospace industry regularly uses PPE to protect workers as well as the spacecraft and aircraft they fabricate in "clean rooms". If officials and citizens called upon all defense contractors and their suppliers to donate non-essential PPE, this would dramatically reduce the supply shortage. Additionally, many of the factories with these supplies are located just a few miles from hospitals in need, reducing many logistics and transportation issues (Los Angeles is a prime example of this).

    REFERENCE

    1. https://boeing.mediaroom.com/2020-01-29-Boeing-Donates-250-000-Medical-Masks-to-Battle-Coronavirus-in-China
    CONFLICT OF INTEREST: Formerly employed by an aerospace defense contractor
    Redirect PPE from Contact Lens Solution Manufacturers and Computer Chip Makers
    Christopher Ryan, MD | Virginia Hospital Center
    Contact lens solution manufacturers and computer chip makers both use sterile gowns, gloves and masks during the manufacturing process. These materials should be redirected to the more urgent needs of front line caregivers.

    Contact lens solution can be rationed and glasses can be worn. Discounted glasses can be made for anyone without glasses.

    Computer chip makers can halt production in sterile rooms and use warehoused chips or stop production of new devices entirely.
    CONFLICT OF INTEREST: None Reported
    PPE From CPAP Equipment
    John Nelson | DME - cpap.com
    On online video demonstrates how to create an N95/100-like respirator from CPAP equipment (1). It's a "bush fix" to be sure, but I share because it's better than nothing, and if you're like us, you've got the materials laying around.

    REFERENCES

    1. https://www.youtube.com/watch?v=1LV3KmVuPRI&authuser=0
    CONFLICT OF INTEREST: cpap.com sells the equipment like that used by the creator of the solution documented in the linked video. We are not affiliated with the content creator.
    MRSA and VRE contact precautions: not needed
    Elizabeth Richardson, MD | University of New Mexico
    Rounding on patients today, I wondered if PPE on my patient with positive MRSA mates was truly necessary. After sharing my sentiments with my upper level resident, he cited and discussed an article published in the Journal of Hospital Medicine (from a series of articles entitled “Things we do for no reason”) entitled “Things we do for no reason: Contact Precautions for MRSA and VRE.” (1) Multiple studies from different academic institutions were citied with conclusions that found PPE precautions are not necessary and may ultimately be harmful to patients in this cohort.

    This may be a perfect time
    to question things that we do in such a time where PPE conservation is needed.

    REFERENCE

    1. Kristen Young, DO, MEd, Sarah B Doernberg, MD, MAS, Ruth Franks Snedecor, MD, Emily Mallin, MD, SFHM, Things We Do For No Reason: Contact Precautions for MRSA and VRE. J. Hosp. Med 2019;3;178-180. doi:10.12788/jhm.3126
    CONFLICT OF INTEREST: None Reported
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    Increase PPE supply & decrease PPE demand with Cause-and-Effect Diagrams
    Paul Mullan, MD, MPH | Children's Hospital of the King's Daughters, Eastern Virginia Medical School
    All of the comments fit into one of two categories - increasing supply (e.g. concentrating PPE from other non-hospital locations, creating respirators and surgical masks from non-traditional supplies, getting industries to start manufacturing PPE) or decreasing demands.

    Both are critical- increasing supplies probably requires more planning/resources/time, while decreasing demands can be addressed on your next shift. Consider applying traditional quality improvement methodologies to address decreasing PPE demands.

    One valuable tool is the cause-and-effect diagram (aka fishbone diagram or Ishikawa diagram (1) used to identify many of your setting's potential factors that contribute to the
    "effect" of using more PPE than might be medically necessary. The "causes" can fall into different frameworks but the most common one for brainstorming the potential causes with frontline clinicians is the 6M model: methods, mother nature/environment, manpower, material, machine, measurement. A brief description and a PPE-demand related example for each of the M's is listed below.

    -Methods (processes): lack of local guidelines for how to clean or avoid contamination of PPE to allow the re-use of PPE for multiple patients.
    -Mother nature (environment): lack of systems to decrease flow of patients into your environment who require staff wearing PPE (e.g. via telemedicine; drive-through testing)
    -Manpower: no standardized criteria for who needs to care for patients in order to limit the number of caregivers and caregiver contacts per patient
    - Materials (consumables): lack of centralized storage of PPE to limit unit-based or individual provider hoarding
    - Machine (equipment): lack of storage systems for reusable PPE (e.g. cubby holes for paper bags to store individual's respirators to extend usage to the individual's next shift)
    - Measurement (inspection, tracking): lack of process metrics to monitor the rate of PPE usage or current supply.

    With an innovative, multidisciplinary group of dedicated people you can add dozens more causes to each of the "M" cause categories listed above. The next step is to organize the various causes into a prioritization matrix to determine which ones to address first - the aim of prioritization is to identify those causes that have the highest degree of impact with the lowest degree of effort (i.e., the "low hanging fruit" or early wins). Prioritization matrix methods are in most QI textbooks as well as online (2)

    Dr. W. Edwards Deming said that "We are here to learn, to make a difference, and to have fun." In spite of the stress on healthcare systems and healthcare providers, thanks to JAMA for providing a forum to learn from others, make a difference for our staff and patients, and have a bit of fun innovating to improve care.

    REFERENCES

    1. https://en.wikipedia.org/wiki/Ishikawa_diagram
    2. https://www.mindtools.com/pages/article/newHTE_95.htm
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    Rapidly Validate Novel Designs and Train Effectively
    Philip Harber, MD, MPH | Mel and Enid Zuckerman College of Public Health, University of Arizona
    Many nonstandard N95 alternatives have been suggested. Rapid evaluation of the effectiveness with standard industrial hygiene filtration efficiency tests can identify those that are useful rather than providing false assurance. Qualitative fit testing a sample will also be useful. Many uncertified products are not effective (1).  Also, proper training, particularly with video demonstrations, is more effective than printed brochures (2).

    1. Cherrie JW, Wang S, Mueller W, Wendelboe-Nelson C, Loh M. In-mask temperature and humidity can validate respirator wear-time and indicate lung health status. J Expo Sci Environ Epidemiol. 2019;29(4):578-583.
    2. Harber P, Boumis RJ, Su J, Barrett S,
    Alongi G. Comparison of three respirator user training methods. Journal of occupational and environmental medicine. 2013;55(12):1484-1488.
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    Autoclave/Reuse Unsoiled Paper Surgical masks
    Brett Coldiron, M.D. | Clinical Assistant Professor, Department of Dermatology, University of Cincinnati, Cincinnati Ohio
    The paper surgical masks we all use can be steam autoclaved. In the office setting we save our unsoiled masks in individual autoclave pouches and sterilize them at the end of the day. No literature on this, since this has never been necessary before in our disposable culture.
    CONFLICT OF INTEREST: None Reported
    N95 FFR decontamination
    Shelley Halpain, Ph.D. | UC San Diego, Sanford Consortium for Regenerative Medicine
    Question for Vicky Cerino of UNMC: how did Dr. Lowe's team validate that

    a) this UV light decontamination method was effective in neutralizing live virus and
    b) that afterwards the masks are still effective in protection and still fit correctly?

    UV light can degrade certain plastics. This sounds like a potentially viable method but can you provide a reference and additional info?

    Another method we are considering is vaporized hydrogen peroxide (VHP), which could be used, for example, in CO2 incubators re-purposed for mask or other PPE decontamination, using methods already established and
    in commericial use for microbial decontamination of such incubators. VHP has been reported to be effective in N95 mask contamination (1).

    REFERENCE

    1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2781738/
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    PPE Not a Silver Bullet to Manage Occupational Hazards
    Kirsten Bobrow, MBChB, DPhil | University of California, San Francisco
    The use of PPE is really about reducing the risk of exposure of frontline health care and associated workers to COVID-19 infection. Worth repeating is that PPE is considered the least effective and last resort in the management of worker health. Reasons for the limited effectiveness of PPE include tolerability (particularly over many hours), technical difficulties (for example, goodness of fit), and continued education on use (e.g. putting on, using, and removal and safe disposal).

    To sustainably manage our PPE stores we need to engage upstream strategies within the NIOSH Hierarchy of Controls; elimination, substitution, engineering and administrative
    controls.

    1. Elimination: Often dismissed as a strategy because we think about eliminating the risk from the worker rather than the worker from the risk. However for some health care workers, particularly those who are older, with co-morbid conditions or immune-compromised, we should aim to eliminate their risk of infection from the health care system. One way is by having them contribute remotely via phone and video-conferencing. For countries where the number of specialist physicians and nurses is very limited it may be prudent to include them as well as it is less possible to currently source additional capacity from other countries.

    2. Substitution: To limit exposure we should start thinking about how we can limit both the number of potentially infectious cases and the number of times health care workers are exposed to an infectious case. This could include training volunteers who are not health care workers to assist with technical tasks that do not require specialized medical training. Ideally, we would prioritize individuals with proven immunity. With many countries enacting a “pause” and workers in several industries unable to work reskilling workers is possible and would engage the public for the time it will take to “flatten the curve”. Process automation using robots for tasks like restocking and cleaning need urgent adoption.

    3. Engineering: Adoption of technologies to support self-assessment, self-administration of swabs for testing, and remote measurement of vital signs. Engineering controls can be used to reduce the potential for contamination across departments and floors by dedicating staff to at-risk areas or not with limited to no potential for cross-contamination (as is already the case with controlled access to ICU). We should also consider organizing staff into cohorts that work together in terms of service length and location (rather than status quo of overlapping and different periodicities and overlapping locations.)

    4. Administrative controls: We need to rethink care workflows. For example, who and how is the initial triage performed, how and to where is an ill patient admitted, and where severely ill patients are managed? Given what is known about the course and indicators which likely predict severe illness an expediently and specifically trained technician supported by computer decision software would be able to perform triage and refer for admission. Admissions could similarly be done by technicians under direct, but remote, supervision by a skilled health care worker (perhaps in-person behind a booth). Engineering and administrative controls can again limit exposure of technicians to acceptable limits without the extensive use of PPE.

    By radically rethinking how to limit exposure of health care workers we can sustainably manage the global PPE supply. PPE never has been a silver bullet to manage occupational hazards and it won’t be now.
    CONFLICT OF INTEREST: None Reported
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    Decrease demand, increase efficiency, and reduce use
    Earl Dorsey, MD | University of Rochester Medical Center, Rochester, NY
    Until the supply of PPE is sufficient, we should (1) decrease the demand for PPE, (2) ensure efficient use of existing PPE, and (3) reduce the use of PPE in the care of individuals with COVID-19.

    1. Decrease the demand for PPE – The mantra should be to keep COVID-19 out of the hospital. Remote diagnosis, monitoring, and care of individuals with (suspected) COVID-19 should be done at home via online screening tools, and phone triage. Remote monitoring (delivering pulse oximeters or wearable sensors to individuals' homes) and remote diagnosis (deliver diagnostic kits to people's homes
    as planned by Gates Foundation) can also be brought to the homes of individuals needing such services. If necessary, hospital-at-home care with virtual, and if needed in-person, visits from nurses and physicians can be provided. These and other measures will keep COVID-19 out of the hospital and reduce the vast majority of demand for PPE. It will also save money and lives.

    2. Increase the efficiency of use – Towers, wings, floors, or sections of the hospital should be designated for these individuals and be as physically separate (even on different campuses) from the main hospital as possible. Alternatively, entire hospitals, urgent care centers, ambulatory surgery centers, clinics, dorms, nursing homes, or other facilities could be used exclusively for those with (suspected) COVID-19 infections. Within each, designate clinicians, ideally from volunteers, who care exclusively for these individuals. These brave doctors, nurses, therapists, aides, technicians, sanitation workers, and food service laborers will all become more efficient with the use of PPE with experience. In addition, following established volume-quality relationships, these workers will become better at caring for individuals with COVID-19. These individuals could wear gold stars (or equivalent) and be physically separated from all other clinicians and health care workers who could wear blue stars. These designations would reduce the risk of transmission of the virus within hospitals and decrease the demand for PPE further.

    3. Reduce use – A small portion of individuals will require hospital-level care. Rooms designated for those with (suspected) COVID-19 should be equipped with 2-way audio and video capabilities so a large portion of care can be provided from outside a patient’s room. The result is that less PPE is used per patient.

    The first goal is to prevent COVID-19 from coming to the hospital or other clinical settings and thus eliminate the need for PPE. For those patients with COVID-19, they should be cared by a dedicated set of clinicians and workers who have no other responsibilities so their efficiency with PPE and proficiency of care increase. Finally, video-connected rooms will allow for care with minimal interpersonal contact and minimal use of PPE.
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    Decontamination Protocols
    Nicholas Hornstein, MD/PhD | UCLA
    I have seen a number of hospitals implementing ad hoc decontamination protocols to extend their current supply of N95 respirators.

    There is a wealth of published literature on UV-C decontamination in the setting of both Influenza and Coronavirus. Additionally, these studies have explored the effects of UV-C on mask fit, filter breakdown, and overall logistics of implementation.

    To summarize briefly, UV-C is a extremely promising avenue for decontamination of unsoiled N95 respirators to extend a dwindling supply. I have compiled a list of pertinent references as well as a summary and have thoughts on protocols which could
    be implemented using pre-existing hospital equipment (such as dermatology phototherapy booths or UV room sanitizers).

    An additional protocol, albeit with less evidence, is a "store and wait" style approach. Based on recently published literature, COVID has a infectivity measured in 24-72 hours while on most (unsoiled) surfaces. Combined with prior studies on Influenza and Coronavirus coated N95 masks, it seems apparent that a "store and wait" protocol of 5-7 days would safely allow for re-use of N95s.

    I have a large amount of literature compiled regarding these approaches, as well as thoughts on implementation and protocols. Please feel free to reach out to discuss further.
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    Orthopaedic Surgical Helmet System (Space Suit)
    Ian Watkins, Medical Student | University of Miami
    Orthopaedic Surgical Helmet Systems (Space Suits) are primarily used for total joints, but can be used for any operation in any specialty. Operating rooms require enormous amounts of PPE as surgical teams and support staff can number around 10 individuals per case. While we have done a good job on reducing the number of elective cases, urgent and emergent cases still need to be performed. By switching to Space Suit systems in these cases, we can free up masks and goggles (up to 10 sets) for use in the ED and the wards.

    REFERENE

    https://www.ncbi.nlm.nih.gov/pubmed/27238610
    CONFLICT OF INTEREST: None Reported
    Cardiovascular Ultrasound in the current pandemic -COVID 19
    Nimesh Patel, MD .FACC | Virginia Commonwealth University
    Sonographers are one of the few healthcare professionals who are at the frontlines and often forgotten personnel taking care of critical patients. Unfortunately, recommended social distancing (>6 feet) cannot be practiced when performing a cardiovascular ultrasound.

    As a provider, I would recommend the following specific protocols to combat the spread of COVID-19.

    1. Reschedule all elective outpatient cases. This will help reduce exposure and adhere to social distancing recommendations.
    2. Develop a team approach when ordering a cardiovascular ultrasound on a suspected or confirmed COVID-19 patient. This should involve discussion with the primary provider and consulting cardiologist.
    This will decrease employee exposure, conserve PPE equipment, and adhere to social distancing recommendations.
    3. Ensure cardiovascular sonographers have reviewed and acknowledged the Donning and Doffing tutorial, which includes proper handwashing and appropriate use of PPE equipment when encountering a suspected or confirmed COVID-19 patient.
    4. Ensure the cardiovascular department is using suitable disinfectant for Philips transducers. Philips transducer disinfectant guidelines are outlined on the following link. http://incenter.medical.philips.com/doclib/enc/fetch/2000/4504/577242/577260/593280/593786/453561739641a_Online.pdf%3fnodeid%3d10164128%26vernum%3d-2.
    Not following transducer disinfectant guidelines outlined by the manufacturer will result in damage of ultrasound transducers. This could lead to patient harm as well as machine downtime due to damaged transducer.
    5. Upon completion of the study, complete thorough cleaning of the affected room. This includes disinfecting the bed, countertops, ultrasound equipment, etc. with appropriate disinfectant.
    6. Limiting staff exposure during the study is vital. This includes having only one sonographer present while performing an ultrasound unless deemed necessary. Avoiding exposure to high-risk staff, such as staff over the age of 50 and those with underlying medical conditions.
    7. Finally, the need to create a positive environment for the sonographer. We salute and appreciate you. Keep each informed of changes, encourage one another, and lastly, be a strong team in your department as well as the entire organization.

    Reference
    1.https://www.asecho.org/ase-statement-covid-19/
    2. http://incenter.medical.philips.com/doclib/enc/fetch/2000/4504/577242/577260/593280/593786/453561739641a_Online.pdf%3fnodeid%3d10164128%26vernum%3d-2
    CONFLICT OF INTEREST: None Reported
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    Available Evidence Supports the Efficacy of Basic PPE
    Sohil Sud, MD, MA | Department of Pediatrics, University of California San Francisco
    In the 1980s, researchers made healthy young adults touch items contaminated with secretions from babies with RSV (countertops, toys, cribs, etc) and told them to then “gently rub the mucous membranes of their nose or eye”. Surprise surprise the volunteers—who never actually saw the babies—contracted RSV around 6 days after exposure [1]. When others acted on these findings and implemented control measures (cohorted nursing, gowning, and gloves – even without masks), nosocomial RSV rates dropped precipitously [2]. Takeaway: watch what you touch and lean on in patient rooms; don’t touch your face; and take contact precautions seriously. />
    But that’s RSV... what about coronavirus? This pandemic strain is called SARS-CoV-2 because of its similarity to the SARS-CoV that wreaked havoc in Asia in 2002. So until we know more, the original SARS-CoV is a reasonable proxy. From retrospective case-control studies about the SARS outbreak, it is clear basic hygiene among healthcare workers goes a long way. Handwashing, gloving, gowning, and masking dropped the odds of worker infection substantially as individual interventions. Doing all of the above plummeted the odds ratio to 0.09 [3]… and this is without PAPRs, negative pressure, etc. Takeaway: do the basic PPE and don/doff well.

    What about aerosols? A recent study caused a stir because researchers found that SARS-CoV-2 can linger in the air for hours in laboratory conditions [4]. Laboratory conditions = rotating drum 21-23 deg C with 65% humidity. How that plays out in the real world is unknown. Sunlight kills influenza aerosols [5], so I hold out hope that that SARS-CoV-2 follows a similar fate. Additionally, in a separate study arm of that 1980s RSV paper referenced above, none of the volunteers who sat in the room 6 feet away from an RSV baby without a mask got infected [1].

    From a practical standpoint, are N95s better than regular masks? Probably yes. Are PAPRs even better? Probably yes. Both provide incrementally more protection, particularly against aerosolized particles. But in the context of limited resources and limited training, are they absolutely necessary? Unclear. Coronavirus is probably spread primarily through large droplets, so a standard surgical mask should help by preventing those droplets from directly entering your nose and mouth, and keep you from touching your own nose and mouth (don’t forget about your eyes though). In one review from the original SARS outbreak, 0 of 51 staff workers who wore a surgical mask got infected, and 0 of 92 who wore an N95 got infected [6]. Both were protective; that bodes well. An RCT (prospective!) of Canadian nurses who were randomized to wear fit-tested N95s or surgical masks (even during aerosolized treatments) during flu season showed almost identical rates of lab-confirmed influenza (within 1%) between the two arms and concluded that surgical masks were non-inferior [7]. Takeaway: if you’re in a setting where N95s/PAPRs are not available or recommended, focus on the basics.

    Personal stethoscopes [8] and personal cellphones [9] can harbor viruses, not just bacteria. Both of the referenced studies checked for viral RNA via RT-PCR, not culture, so we don’t know if the viruses were alive and communicable. But still, eww. Take away: don’t use personal phones in patient rooms; clean your equipment often and well.

    REFERENCES

    [1] https://www.ncbi.nlm.nih.gov/pubmed/7252646
    Hall CB, Douglas RG Jr. Modes of transmission of respiratory syncytial virus. J Pediatr. 1981 Jul;99(1):100-3.
     
    [2] https://www.ncbi.nlm.nih.gov/pubmed/?term=1357462
    Madge P, Paton JY, McColl JH, Mackie PL. Prospective controlled study of four infection-control procedures to prevent nosocomial infection with respiratory syncytial virus. Lancet. 1992 Oct 31;340(8827):1079-83.
     
    [3] https://www.ncbi.nlm.nih.gov/pubmed/18042961
    Jefferson T, Foxlee R, Del Mar C, et al. Physical interventions to interrupt or reduce the spread of respiratory viruses: systematic review. BMJ. 2008 Jan 12;336(7635):77-80. Epub 2007 Nov 27.
     
    [4] https://www.medrxiv.org/content/10.1101/2020.03.09.20033217v2.full.pdf
    van Doremalen N, Bushmaker T, Morris D, et al.  Aerosol and surface stability of HCoV-19 (SARS-CoV-2) compared to SARS-CoV-1 (pre-print) doi: https://doi.org/10.1101/2020.03.09.20033217
     
    [5] https://www.ncbi.nlm.nih.gov/pubmed/31778532
    Schuit M, Gardner S, Wood S, et al. The Influence of Simulated Sunlight on the Inactivation of Influenza Virus in Aerosols. J Infect Dis. 2020 Jan 14;221(3):372-378. doi: 10.1093/infdis/jiz582.
     
    [6] https://www.ncbi.nlm.nih.gov/pubmed/12737864
    Seto WH, Tsang D, Yung RW, et al; Advisors of Expert SARS group of Hospital Authority. Effectiveness of precautions against droplets and contact in prevention of nosocomial transmission of severe acute respiratory syndrome (SARS). Lancet. 2003 May 3;361(9368):1519-20.
     
    [7] https://www.ncbi.nlm.nih.gov/pubmed/19797474
    Loeb M, Dafoe N, Mahony J, et al. Surgical mask vs N95 respirator for preventing influenza among health care workers: a randomized trial. JAMA. 2009 Nov 4;302(17):1865-71. doi: 10.1001/jama.2009.1466. Epub 2009 Oct 1.
     
    [8] https://www.ncbi.nlm.nih.gov/pubmed/31668149
    Phan LT, Sweeney D, Maita D, et al; CDC Prevention Epicenters Program. Respiratory viruses on personal protective equipment and bodies of healthcare workers. Infect Control Hosp Epidemiol. 2019 Dec;40(12):1356-1360. doi: 10.1017/ice.2019.298. Epub 2019 Oct 31.
     
    [9] https://www.ncbi.nlm.nih.gov/pubmed/?term=27030915
    Cavari Y1, Kaplan O2, Zander A1, et al. Healthcare workers mobile phone usage: A potential risk for viral contamination. Surveillance pilot study. Infect Dis (Lond). 2016;48(6):432-5. doi: 10.3109/23744235.2015.1133926. Epub 2016 Feb 5.
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    Reusable Cotton Superior to Disposable Material
    Robert Mc Ginnis, MD, MSEE | None at this time
    In an era of high tech when people tend to think of disposable materials for making PPEs, one free online article indicates that reusable cotton is superior to disposable material gown material (1). In Table 1 of the paper, for example, cotton was superior to disposable gown material by a factor of 2 to 24. It is something to consider in thinking about making PPEs such as robes, hoods, masks, etc. Cotton is washable and can be reused.

    REFERENCE
    1. https://academic.oup.com/cid/article/41/7/e67/310340
    Survival of Severe Acute Respiratory Syndrome Coronavirus
    Mary Y. Y. Lai, Peter K. C. Cheng, Wilina
    W. L. Lim
    Clinical Infectious Diseases, Volume 41, Issue 7, 1 October 2005, Pages e67–e71,
    https://doi.org/10.1086/433186
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    Bed Bug sheets
    Janielle Nordell, MD | Mayo Clinic Health System
    I've been doing research today on how to make effective DIY masks that actually filter SARS-CoV-2. The virus is 0.125 microns -N95s have 0.3ish porosity but still work pretty well. Some bedbug sheets have 1 micron porosity (WAY better than most fabrics and such) and is breathable - and can be laundered - and one sheet could make over 200 masks.

    Has this fabric been tested?
    CONFLICT OF INTEREST: None Reported
    Ultraviolet Decontamination of N95 Filtering Facepiece Respirators
    Mark Rupp, MD | University of Nebraska Medical Center
    (Editor's Note: This comment describes the same initiative noted in the 5th comment by Vicky Cerino)

    The ongoing pandemic of SAR CoV-2 resulting in COVID19 has severely stressed the worldwide healthcare system and has created dangerous shortages of personal protective equipment (PPE) including N95 filtering facepiece respirators (N95 FFR). In an effort to extend the stockpile of N95 FFRs at our institution, we developed a decontamination procedure involving the delivery of ultraviolet germicidal irradiation (UVGI) to used N95 FFRs. The evidence base supporting this program includes: 1) UVGI has been shown to effectively inactivate a wide range of
    human pathogens including coronaviruses and other human respiratory viruses; 2) UVGI has been demonstrated to inactivate human respiratory viruses, including coronaviruses, on various models of N95 respirators; 3) levels of UVGI needed to inactive human respiratory viruses are well below the level of irradiation that adversely affects the fit and filtration characteristics of N95 FFRs; and 4) UVGI can be safely administered when appropriate safeguards are in place. Herein, we briefly describe our procedure to decontaminate and reuse N95 respirators.

    Used N95 FFRs are subjected to UV-C at an exposure of 60 mJ/cm2. Single-stranded RNA viruses, such as SARS-CoV-2, are generally inactivated by UV-C exposure of 2-5 mJ/cm2 (1). Thus, the UV-C exposure we have chosen exceeds, by at least several fold, the amount of exposure needed to inactivate SARS CoV-2 and provides a wide margin of safety. Respirators are secured on wires that are strung across a room with two UV towers (ClorDiSys UV-C Light System, https://www.clordisys.com/products.php) on either side. Our UV-C towers are equipped with eight 254 nm bulbs that are routinely used in biosafety cabinets and produce 200 μw/cm2 at 10 feet distance for a dosage of 12 mJ/minute. We monitor the delivered UV exposure dose with a UV meter that can be initiated and monitored from outside the room to verify that the desired exposure has been achieved. We plan to decontaminate and reuse the N95 respirators multiple times until respirator fit is impacted (2-4). Prior to initiating the decontamination program, the walls and ceiling were covered with a UV-reflective coating (https://lumacept.com) with which our group had experience (5). Our program initially involved the units with high N95 respirator use such as the emergency department and our COVID19 ward, but we plan to rapidly expand to ambulatory settings. We believe a variety of UV light sources could be used in a similar fashion including UV equipped biosafety or sterilization cabinets or other UV disinfection systems and that this method can be applied to a variety of other critical items such as procedure masks.

    A full description of our UV-C N95 FFR decontamination program is available at https://www.nebraskamed.com/sites/default/files/documents/covid-19/n-95-decon-process.pdf

    REFERENCES

    1. Chun-Chieh Tseng & Chih-Shan Li (2007) Inactivation of Viruses on Surfaces by Ultraviolet Germicidal Irradiation,Journal of Occupational and Environmental Hygiene, 4:6, 400-405, DOI: 10.1080/15459620701329012

    2. Michael B. Lore, Brian K. Heimbuch, Teanne L. Brown, Joseph D. Wander, Steven H. Hinrichs, Effectiveness of Three Decontamination Treatments against Influenza Virus Applied to Filtering Facepiece Respirators, The Annals of Occupational Hygiene, Volume 56, Issue 1, January 2012, Pages 92–101, https://doi.org/10.1093/annhyg/mer054

    3. Dennis J. Viscusi, Michael S. Bergman, Benjamin C. Eimer, Ronald E. Shaffer, Evaluation of Five Decontamination Methods for Filtering Facepiece Respirators, The Annals of Occupational Hygiene, Volume 53, Issue 8,
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    Ultraviolet Germicidal Irradiation for N95 masks using community resources in a pandemic induced shortage
    Jon McGuire, BS/MS Optical Engineering | Independent consulting optics/laser/systems engineer, and member of the community.
    Using Ultraviolet Germicidal Irradiation (UVGI) to disinfect N95 filtering facepiece respirator (FFR) masks offers an opportunity to effectively turn every one (1) mask into the functional equivalent of fifty (50) or more. The effects of Ultraviolet C-band (UV-C) radiation at 254nm on a broad class of virulent organisms has been well studied and accepted as a means by which to inactivate them. The UVGI method and application to N95 masks specifically were studied after the SARS, MERS and Ebola outbreaks of 2000’s - wherein a shortage of N95 masks in each emergency reduced the effectiveness of frontline healthcare providers or increased the risks they took in providing effective care. Using devices that are well proliferated within local communities, namely commercial UVGI sanitizers, shortages of N95 masks and procurement delays of ordering new masks or UVGI equipment can be mitigated immediately. With support in the form of donations of these devices from the local community, we can protect our medical professionals providing aid during this COVID-19 disaster at a rate, timing, at a level no foreseeable scale of production of new masks possibly can. It is the goal of this submission to briefly summarize the effectiveness of such an option for the medical, and political decision makers who are driving the outcomes of this disaster, and to positively influence their decisions, without the requirement for reading the extensive technical research in the area.

    By using existing devices, hospitals can implement a simple and effective UVGI protocol that provides for the safe reuse of N95 masks by the healthcare workers who are putting themselves at risk while caring for those in need. They must be instructed to do so from the WHO, CDC, or any other authority which can make such policy directives. With volunteered UVGI devices from within each localized community, and if required validation from community members expert in the arena, we can collectively arise to meet the challenge of this unique time, both immediately and for the duration.

    Full discussion available at https://bit.ly/UVGI-N95
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    Improvised Droplet Barrier for Outpatient Primary Care and Urgent Care Clinics
    Alison Craig-Shashko, MD | Group Health Cooperative of South Central Wisconsin (Madison)
    My team and I built a droplet barrier for clinic COVID-19 testing to preserve PPE.

    An image is at https://www.facebook.com/674792030/posts/10157069207107031/?d=n

    I describe its materials and construction at https://youtu.be/nMLW_w-t2cc

    608-345-2076
    CONFLICT OF INTEREST: None Reported
    Breathing System Filters on 3M Reusable Respirators through 3D-Printed Adapters
    Dexter Liu, MB BCh | Department of Anaesthesiology & Pain Medicine, United Christian Hospital, Hong Kong
    There have already been numerous suggestions involving 3M reusable respirators and N95/P100 filters on this page. The demand of these filters has surged and has undoubtedly overwhelmed supply.

    We have designed a 3D printed adapter that allows the usage of breathing system filters (those used in anaesthetic circuits and ventilators) on 3M reusable respirators. They are very effective in filtering bacteria and viruses, relatively low cost compared with N95/P100 filters and are readily available in any operating theatre or ICU.

    We modified the 3M 6000 and 7500 series reusable respirators such that both inhalation and exhalation occurred through
    a single breathing system filter, protecting both the user and others.

    We have just completed a volunteer study and tested these modified respirators/breathing system filters with a PortaCount Pro 8038 Respirator Fit Tester (TSI Incorporated). We used the built-in N95 protocol and performed rigorous testing to detect potential air leak during neck movement or talking which may compromise staff safety.

    Our main findings:
    1. All 8 volunteers obtained perfect fit test results.
    2. None of the volunteers experienced any major discomfort.
    3. All 8 volunteers had normal end-tidal carbon dioxide values after 1 hour of continuous usage.

    Our results indicate that these modified respirators are safe and viable alternatives to disposable N95 respirators in these desperate times.
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    ProtectHealthCareNow - immediate Donation of PPE from other branches
    Susanne Manthey, Architect, Berlin Germany | Public administration - Construction
    Fundraising campaign for protective equipment for use in the medical field and by the emergency services

    (from inventories privately or from other industries, since there is currently not enough goods on the market, so in China and Germany, too, the voluntary commitment to redistribute over and under capacities was used)

    - If possible, distribute information via Twitter, social media, news blogs and articles in newspapers and television stations or simply pass this information on by email

    - Surplus protective equipment, if possible (to be coordinated with the authorities), should be handed in to the KVE (National Association
    of Statutory Health Insurance Physicians) of the federal states

    or health ministries,

    - if or for as long as this is not possible, hand it in to the doctor's office, fire brigade, police nearby if they need it - do not call beforehand (otherwise it clogs the communication channels), it is better to simply bring them over.

    - Donated goods: disposable protective clothing (suits, smocks, if necessary, firm adhesive tape), protective masks of all kinds, protective goggles, disposable gloves, disinfectants, adult diapers (necessary / helpful for long work in protective suits), disinfectants (all only unused and, if possible, in their original packaging)

    - Delivered either directly by donors (e.g. from citizens, construction industry, craftsmen, museum restorers, manufacturers, retailers and large hardware stores with remaining stocks, factories, other groups of doctors e.g. dentists, resident surgeons with stocks, recycling companies, power plants, directly to Collection points,

    - Distribution by the public administration via a tried-and-tested standard route to insufficiently supplied medical practices as well as to emergency officers from the police, fire brigade, emergency services and, if necessary, also to clinics, nursing homes etc.

    - Any excess capacities that may arise should be shared among the state health and safety ministries as needed

    - After the epidemic has died down in one federal state or in all of the state, if necessary, donate goods, respirators and, if possible, also personnel to other countries worldwide, if production is still not sufficient worldwide, otherwise centrally store material and exchange it again and again (see old Senate reserve in Berlin).

    Thank you and good luck to all of us.

    Stay healthy.
    CONFLICT OF INTEREST: None Reported
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    Motorcycle Helmet With N95 and Oxygen
    Richard Collins, MD, Boarded in Cardiology | Retired Cardiologist. On Adjunctive Faculity University of Nebraska Medical Center, Omaha, NE
    The best method is to protect the head, respiratory system, eyes, nose and oral airway. An easy solution: buy a motorcycle helmet with shield, wear a N95 mask beneath. If positive air needed in the system which would be the best idea, place an oxygen catheter over nose or inside the helmet and portable oxygen concentrator on a back pack. No need for a gown, just scrubs. and wear gloves from patient to patient. Then shower with soap and water with helmet on after shift (it is water proof), remove everything and shower completely with soap. Dry helmet and place helmet in Utraviolet light, change into new scrubs and glove again for the next shift. I believe it will work and is sustainable.
    CONFLICT OF INTEREST: None Reported
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    Minimizing Exams That Do Not Change Patient Management
    Yasir taha, MD FACC | University Hospital
    Minimize exams by several providers during the day that rarely change management significantly by itself; one exam per day for ICU patients unless a clinical change justifies repeat examination and is thought to impact management.

    Adopt a virtual exam using microphones and cameras and vital signs and general condition +\- labs and imaging for less sick patients.

    Finally, here is a reference to an article about wireless remote control for ventilators that will protect staff and conserve PPE (1).

    REFERENCE
    1.  A wireless real-time remote control and tele-monitoring system for mechanical ventilators. https://ieeexplore.ieee.org/document/7836121
    CONFLICT OF INTEREST: None Reported
    Economical DIY-PPE for Low-Middle Income Countries and Low Income Countries
    Suryasnata Rath, MS FRCS (Glasgow) | L V Prasad Eye Institute, Bhubaneswar, India
    Considering the current scenario of the COVID-19 pandemic, rapid spread in India, and huge shortage of personal Protective equipment (PPE), we have an economical do-it-yourself (DIY) solution for making PPE. that uses a gown, a cap, protective glasses, gloves, a facemask, and shoe-cover.

    We use thin impervious plastic for the gown. The plastic is easily available as a roll with 2 layers fixed at borders and 3 feet wide. The disposable gown is made like a "poncho" with holes for neck and hands. Masks can be surgical masks (1-3 layers) or N95 as is available. Cap, gloves,
    shoe cover and protective eye wear are included in PPE gear.

    Highlights:
    1. This set of PPE is likely to be light and impervious to droplets. Removal of PPE can be carefully done aided by another health worker and disinfected before disposal.
    2. It is low cost made from locally available material
    3. Disinfection is as easy as its plastic and can recycled after ETO
    4. Mask is separate and can be N95, 3 surgical masks layered, or a cloth mask based on risk level of exposure.

    After exposure is over the PPE needs disinfection. The gown is easily removed by cutting it at the shoulders and allowing it to fall down. The face mask, gloves, shoe-cover and cap is carefully removed with care not to touch the outside surface. All of this can be placed in another plastic bag and disinfected by Ethylene Oxide cycle.

    This PPE set could be made at our institute at a cost - USD 1.50 or INR 100.00

    Picture(s) of the PPE and video showing removal can be shared if needed.
    CONFLICT OF INTEREST: None Reported
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    Consensus Recommendations Needed for DIY mask/face-shield donations
    Virginia Lanzotti, Nurse Practitioner | Washington University School of Medicine
    I have been researching and prototyping face mask designs with input from people who have experienced this outbreak in Asia and Europe. Here is a curated list of recommendations I have compiled.

    1) Mask must have filter pocket (Avoid simple two fabric layer design)
    2) Preferred filter material is 8 layers of t-shirt type material (which can be bleached and reused)
    3) Preferred mask material is woven cotton (washable at high temperatures)
    4) Preferred ties are nylon or cotton, NOT elastic straps which break down when boiled. (They boil them in between uses in Europe)
    5) I make mine
    with a 6 inch nose wire and a single 37 inch adjustable loop of cord. Nose wire improves upper seal, cord around head eliminates gaping caused on the vertical edges caused by around the ear style

    A FORMAL statement from a trusted medical authority would eliminate confusion among well-intentioned but sometimes under informed community members who don't know which mask to make, and what will or won't be accepted by hospitals. Currently CDC has a statement about bandanas or scarves being acceptable in a crisis, but there are scores of volunteers willing to make masks to specification that would be far superior. I will gladly share photos, my exact pattern, measurements upon request.
    CONFLICT OF INTEREST: None Reported
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    Personal Protective Equipment and other essential items
    Sam Ebenezer Athikarisamy, MD FRACP | Perth Children's Hospital
    PPE and other essentials:

    Personal Protective Equipment:
    1. Limiting the PPE use by cutting down or cancelling all elective works
    2. Collecting masks from dental clinics and nail spas
    3. Cloth apparels can make new masks and gowns
    4. Sterilized surgical gowns

    Isolation rooms & other supporting equipment:
    1. As hospitals may run out of spaces, we need to look other alternate places where patients can be cared.
    Operating Theaters can be converted to isolation/ICU
    Hotels, Malls and marriage halls where there is uninterrupted power supply
    Cots (in a country like India Trains are an alternate to function as a hospital- /> Every compartment can be converted into at least 9 Isolation beds)
    Grounded cruise ships
    2. Ventilators and CPAP/HHF equipment
    More service engineers to support if there are any equipment faults
    Inventory of ventilators available in the region
    Pediatric and neonatal ventilators can be converted to adult with software update
    3. Ventilator circuits
    4. Oxygen cylinders
    5. Pulse oximeters
    6. Portable blood gas analyzers (i-stat)
    7. Portable X-ray machines
    8. Enough stock of essential medications

    Human resources:
    1. Critical care specialists, ED physicians
    2. Clinicians senior and junior staff
    3. Nursing staff (ICU trained and general nursing staff)
    4. Para-medical staff
    5. Social workers and counselling personnel for psycho-social support
    6. Hospital support staff including kitchen staff
    7. Military and para-military as standby

    Miscellaneous:
    1. Printed protocols regarding intubation criteria/admission to critical care
    2. Weight based drug infusion charts for all common ICU drugs
    CONFLICT OF INTEREST: None Reported
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    Reusable sustainability
    Jennifer Lin, MD | San Mateo Medical Center
    I think we need to be reusable since supplies are low and suppliers are slow to make more given delays in China. I think a cheap solution is to give every healthcare worker a reusable plastic face shield like welders use, and have them wear a mask underneath that can be reused (either hospital grade N95 if available, or a cloth mask with insert for activated carbon filter to mimic N95). Presumably if the mask is shielded from the patient by a plastic layer, then it is truly acting only as a filter for aerosolized particles. It can be reused all day. The plastic shield can be wiped down with alcohol wipes or bleach between patient interactions. Every healthcare worker, nurse or doctor, needs to have a reusable face shield, and either disposable mask (N95 preferable) or reusable mask with filter as a less desirable option. If reusing N95, hospital FIT testers should test the quality of the mask every day to ensure it is still performing to standard.
    CONFLICT OF INTEREST: None Reported
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    Far-UVC (~222nm) for In-Vivo Sterilization.
    Dimitri Dimitroyannis, PhD | Edward Hines, Jr. VA Hospital, Hines IL
    Above this entry is mentioned the use of Ultraviolet-C (UVC, 254nm or longer wavelengths) as a surface/superficial sterilizing agent for the problem at hand. However, UVC sterilization can only occur in properly shielded areas and in the absence of humans ( patients, care providers) due to the known adverse effects of exposure to these wavelengths, mainly the risk of iatrogenic skin malignancies. Such hominem sine use of UVC light for the reclamation of PPEs has been ingeniously deployed by a group at the University of Nebraska [1]. 

    Interestingly, work produced at the D.J. Brenner lab in New York
    reveals that exposure to shorter wavelengths (far-UVC ~220nm) maintains the germicidal efficiency of UVC while offering mammalian skin protection [2,3]. Others have confirmed the long term safety of the use of far-UVC as an uninhibited sterilizing agent even during surgery [4]. Brenner himself presented the potential of far-UVC light as a robust, safe and inexpensive area sterilizer during a technically accessible TEDx presentation [5]. Far-UVC continuous light treatment has been shown to attenuate both viral and bacterial burden by up to 5 log (for realistic time exposures, and for available power light sources), reducing the need for exotic PPEs to control infection transmission.

    For sterilization beyond/deeper than the surface of PPEs, we can always revert to megavoltage electron beam irradiation, a well studied and reliable option. In fact, following the anthrax incident in October 2001, the USPO irradiates mail addressed to certain addresses in zip codes 202xx-205xx [6]. Therefore capacity does exist to allow for certain PPEs within the mid-Atlantic region to be sterilized during the current emergency, and the recipients of irradiated mail, I trust, will not mind donating any of their "beam-time" if so needed.

    REFERENCES

    [1] NYTimes.com: As Coronavirus Looms, Mask Shortage Gives Rise to Startling Solution, https://nyti.ms/3b8C1HQ

    [2] Welch, D., Buonanno, M., Grilj, V. et al. Far-UVC light: A new tool to control the spread of airborne-mediated microbial diseases. Sci Rep 8, 2752 (2018). https://doi.org/10.1038/s41598-018-21058-w

    [3] Buonanno M, Ponnaiya B, Welch D, et al. Germicidal Efficacy and Mammalian Skin Safety of 222-nm UV Light. Radiat Res. 2017;187(4):483–491. doi:10.1667/RR0010CC.1

    [4] Narita K, Asano K, Morimoto Y, Igarashi T, Nakane A (2018) Chronic irradiation with 222-nm UVC light induces neither DNA damage nor epidermal lesions in mouse skin, even at high doses. PLoS ONE 13(7): e0201259. https://doi.org/10.1371/journal.pone.0201259

    [5] A new weapon in the fight against superbugs, Dave Brenner, TED VancouverBC, April 2017, https://youtu.be/YATYsgi3e5A

    [6] Mail Security. "Is Mail ever Irradiated?" (active link as of 22-March-2020), https://faq.usps.com/s/article/Mail-Security
    CONFLICT OF INTEREST: None Reported
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    Nursing Video consulting
    Julie Davis RN CSN, Registered Nurse BSN CSN | Public health Nurse Consulting/ School health/ clinical assessment/ nursing procedure education
    I have been doing live video RN consulting in my school district for at least 2 years. You would cut down on most PPE equipment and you would be able to visually see and assist patients; specimens can be picked up by lab transporters, tests from a single residence could be traced, patients that would need emergency care could be referred to health facilities awaiting arrival with information already received, test included. Maybe high risk areas can have RN managers and they can do initial screenings with follow up.  People can be safely cared for at home and PPE waste is controlled. This is a doable and practical idea.

    Also with PPE, I am an older Nurse 35+ years, we used linen and cloth material that could be laundered, instead of thrown away, This can protect our health care workers have PPE be laundered at hospitals, we did this when we did Cesarean Sections back in the day , i am still here , it worked a little.... My area of experience is Labor and delivery , Neonatal ICU, ER/ OR obgyn, pediatrics, public health employee health, nursing training for procedures and clinical assessment.

    I do pediatric and staff clinical assessment and RN Referrals for treatment needed or evaluation needed by PCP, I am the Video Nurse consultant for our district and it works well. We have a very high non-insured community in which i live in. I do have ideas that may work and are cost effective, not a lot of us older nurses are still practicing, but we are here. Let me know if you are interested in my ideas of what solutions we can bring to the table.
    CONFLICT OF INTEREST: None Reported
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    Decontaminating N95 Respirators For Reuse
    Risa Wong, MD | University of Washington / Fred Hutchinson Cancer Research Center
    Decontamination of N95 respirators for reuse has been studied in the context of pandemic influenza preparation. Most techniques have at least limited validation using H1N1 as the studied organism. With all techniques, the trade-off is efficacy vs. damaging or shortening the lifespan of the N95.

    Per some experts, the simplest and most practical method at the individual provider level may be surface decontamination with bleach wipes, all surfaces and straps, without soaking. Soaking has been tested before but can cause respiratory and skin problems for some. The vast majority of infectivity concern with reuse comes from surface contamination, as
    the more deeply embedded viral particles would not typically re-aerosolize in normal use.

    Use of quaternary ammonium compound solutions is not recommended, as buildup of residues can affect mask function. Alcohol solutions are also not recommended as they can neutralize the electrostatic charge of the filter elements that trap particles smaller than the mechanical filtration can accomplish.

    On an institutional level, hydrogen peroxide vapor (HPV) may be one of the best solutions because it appears to be highly effective for disinfection (using a G. stearothermophilus assay), it offers a relatively high number of disinfection cycles before causing degradation to the respirator straps (OK up to 20 cycles, degraded at 30 cycles) and the filtration effectiveness remained largely unchanged through 50 cycles. One problem is that no direct study of HPV on N95 respirators using a viral model have been done, though HPV in general is effective on viruses (including a SARS-CoV surrogate envelope virus) and spore formers. Some hospitals already have a HPV decontamination device.

    UV germicidal irradiation (UVGI) has also been fairly well validated against H1N1. The intensity of the UV-C source and the duration of sterilization are both factors to consider. A practical limitation is that degradation of the polymer material of the respirator does occur with UV-C. For most N95 respirators tested, somewhere between 5 and 8 J/cm2 is needed for 4+ log reduction of H1N1. Mechanical degradation of the shells occur at many hundreds of J/cm2 depending on the specific respirator. Bare UV-C sources are reasonably available in the consumer market, most commonly found for use in HVAC systems. Quantification of effective output at the treatment surface is needed to ensure appropriate dosing to ensure efficacy, for example with a UV-C meter.

    Steam, autoclave, moist heat incubation, and dry heat have also been tested. There have been pilots of microwave steam bags and steam chambers. These methods have potential, but in some studies were found to damage the respirators.

    Selected References (more can be provided upon request):
    * https://journals.sagepub.com/doi/pdf/10.1177/155892501000500405
    * https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2781738/
    * Personal communication with expert at Applied Research Associates
    * https://www.ncbi.nlm.nih.gov/pubmed/10957816
    * https://www.fda.gov/emergency-preparedness-and-response/mcm-regulatory-science/investigating-decontamination-and-reuse-respirators-public-health-emergencies (can download final report on website)
    * https://www.journalofhospitalinfection.com/article/S0195-6701(14)00059-0/fulltext
    * https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4699414/pdf/nihms747549.pdf
    * https://www.ajicjournal.org/article/S0196-6553(18)30140-8/pdf
    * https://journals.plos.org/plosone/article?id=10.1371%2Fjournal.pone.0018585
    CONFLICT OF INTEREST: None Reported
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    Ethylene Oxide (EtO)-based Decontamination of Masks and Reprocessing
    Alexis Ball |
    I agree with comment titled "Why not do it the same way it was originally done?" regarding the usage of established sterilization methods to decontaminate masks. Commercial reprocessing of other medical devices classified as single patient use exists already (1). Ethylene Oxide (EtO) is an efficacious way of decontaminating used equipment without damaging the material composition of the device. Decontaminated devices are then washed to restore them to the look and feel of a new product.

    The infrastructure to perform reprocessing including the manufacturing labor and sterilization equipment are readily available without the need to
    purchase new equipment or build up a new supply chain. Vendors such as Steris (2) or similar, there are other vendors in this market, can sterilize collected masks and a dedicated repossessing vendor like Midwestern Reprocessing Center (1), or similar (3) would be able to sort, mark, and package the decontaminated masks.

    A study to determine how many times a mask could be reprocessed would need to be done. The reprocessing vendor could mark the mask each time it is reprocessed with an additional mark in order to allow mask usage to be limited a number that is known to meet the same standards as a new masks. A final quality check could also be done by the reprocessing vendor to ensure the masks are able to meet initial quality specifications.

    Given the extra steps needed in order to ensure quality and cleanliness of reprocessed masks it is probable that this solution would be less economical than simply buying new masks. With that said I would expect the cost to be only marginally higher than buying new masks and it could be worth looking into this further.

    REFERENCES

    (1) https://www.accessdata.fda.gov/cdrh_docs/pdf10/K101330.pdf
    (2) https://www.steris-ast.com/
    (3) https://www.marketwatch.com/press-release/medical-device-reprocessing-market-2019-top-dominating-players-johnson-johnson-vanguard-ag-medtronic-steripro-canada-pioneer-medical-inc-agito-medical-ge-healthcare-soma-technology-inc-siemens-healthineers-2019-04-05
    CONFLICT OF INTEREST: None Reported
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    School Health/University Health Services
    Rose Donepanya, BS | Northwestern Medicine
    With the closure of schools nationwide, there may be a significant number of PPE sitting in Health Service Offices for K-12 schools including the Private school and Charter School systems along with Universities On-Campus Clinics. I have been in contact with our local Health Services Director for the school district.
    CONFLICT OF INTEREST: None Reported
    How I Recycle my Own N95 Respirator
    Mushu Ballooh, M.D. | Hospital in N.B., Canada
    I was fitted with an N95 respirator. Kimberly-Clark, Tecnol Fluidshield PFR95, model 46767.
    If I wear a fresh mask while tending to a PUI patient, whose Covid-19 test results are still unknown, then afterwards I doff it as recommended. then I have a doubled-up see-through tough plastic bag ready, ex large freezer bag; I dangle the mask by the rubber band where I just touched it to doff it, and I push it into the plastic bag, with one finger pushing on the face-side surface. Then I put a label on the bag with the date and patient name,
    and store the bag with the used mask in a closed container. When the Covid-19 test result comes back, and it is negative, I record the “neg” on the bag, as well. Then I leave the bag alone until a future time when I might run out of fresh masks. Then I will have stacked up a good number of used but Covid-19 free masks, for re-using. By that time, any virus might be dead already anyways.
    CONFLICT OF INTEREST: None Reported
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    A Low Cost Innovation for Isolation Gowns
    Arnold Cohn, MD | Northshore University Health System-Emeritus
    The current covid-19 pandemic has led to a shortage of personal protective equipment for medical workers. I have a low tech concept for very inexpensive isolation gowns, made from readily available poly sheets, bags and elastic bands.

    Poly sheets and bag stock are widely manufactured in the US and world wide. I have designed a simple gown, a pancho like device made from a sheet of poly, using poly bag stock for sleeves and boots. The sleeves are fabricated from one long piece of bag stock, and worn under the pancho. Excess material is bound
    with the elastic or rubber bands. A waist string would also be provided.

    These gowns could be supplied for a few cents, and could be changed frequently. A simple instruction sheet would allow the gowns to be fabricated as needed on site, in just a minute or two.

    The advantage is low cost, and material that is already available. No special manufacturing needed. These gowns would not be as protective as a standard isolation gown, but in the event of shortages, these gowns would be much better than forgoing protection.

    Although the poly gowns could be made from locally available materials, it would be more efficient to package the materials and instructions in a plastic bag and distribute world wide. I am attempting to contact leaders and decision makers. This concept could become a reality quite quickly.
    CONFLICT OF INTEREST: None Reported
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    PPE "Bounties"
    J Jackson, BA | Seattle
    Medical administrative staff should be tasked exclusively with hunting down non-traditional sources - boat repair & supply, auto parts shops, hardware stores (especially building/construction contractor), dollar stores, art supply stores. Obviously front-line staff has more urgent priorities, but rather than dismiss unnecessary staff, offer a "bounty" for PPE that is discovered thru online searches or in one's own neighborhood (during a necessary supply run).

    The "bounty" could consist of future PTO, or discounts on future care / prescriptions if no longer with the institution. A lot of people would be willing to help for free, just because, but
    don't know who to get them to, or can't afford to reserve the stock by themselves.

    The general public doesn't realize the dire state things are in - Thank you to those health institutions whose management is fully transparent about uncomfortable truths, and for being willing to brainstorm.
    CONFLICT OF INTEREST: None Reported
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    Creative Ideas for Reusable PPE
    Elizabeth Dorn, MD DTMH | University Washington
    Respirator masks used in construction are made of plastic and silicone
    they completed seal around the nose and mouth and
    offer 99.97% respiratory protection depending on the filter
    they can be re-used
    they can be washed after every shift and even between patients
    they last for years
    every member of the ED staff could have one, and replace the filter every shift ( maybe longer- though they can not be washed in soap and water- and the outside cartridge would need only be wiped down with bleach)

    The problem is:
    Expiration is not filtered
    on the way out, though goes through a diaghram
    Would a surgical mask over the outlet mitigate this issue? in order to protect the patient as well
    though that would only be important for COVID-+ providers (and we don’t always know who they are)

    The ultimate benefit of this is they would filter nearly 100%  not met by our N95, and less so with re-use, and might better protect our staff as we enter this upcoming highly like surge of patients and not run out
    CONFLICT OF INTEREST: None Reported
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    Resupply From China
    Dejun Shen, Staff pathologist | SCPMG, Staff Pathologist
    The Chinese government now owns 2/3 of the PPE in the world and China's own need for PPE is declining. If the US government can call the Chinese president to request PPE, resupply will be quite easy.
    CONFLICT OF INTEREST: None Reported
    Reuse PPE after right treatment
    Duo Li, MD & PhD | Second Xiangya Hospital, Central South UniversityChangsha, Hunan 410011, China
    In the outbreak days of COVID-19 in China, some hospitals experienced the severe shortage of personal protective equipment (PPE). To my knowledge, some methods were adopted or created to extend PPE’s service time or reuse them.

    1) Gloves were sprayed with 75% alcohol to disinfect them and avoid intensive glove changes.
    2) Goggles were reused after 75% alcohol disinfection or high-energy ultraviolet irradiation for 1 hour.
    3) Medical masks used once were placed in an oven over 56 degrees for 1 hour to kill viruses, then treated by using a hair dryer to heat 10 minutes
    for the recovery of charge. These treated masks can be worn by the same user again. Furthermore, medical N95 mask were replaced by one industrial N95 mask plus one surgical mask in the emergency.

    Hope everyone stays home as much as possible to limit the COVID-19 pandemic. And if you have PPE, please donate them to medical organizations.
    CONFLICT OF INTEREST: None Reported
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    Elevated temperature and humidity have been shown to decrease/eliminate infectivity of SARs coronavirus
    Robert Mc Ginnis, MD, MSEE | None at this time
    "We and others have shown that the infectivity of SARS CoV (SARS Coronavirus) was lost after heating at 56 degrees C [133 degrees F] for 15 minutes ...."

    If the SARS-CoV-2 virus that causes COVID-19 is similar, then exposing a used PPE to what is a relatively low temperature (> 133 degrees F) for a relatively short amount of time (> 15 minutes) will effectively allow reuse of the PPE. Such low temperatures can be easily achieved in an ordinary kitchen oven and the temperature monitored with a candy thermometer in a coffee cup in the oven. Also
    putting a cup with water in it in the oven might increase the effectiveness of the treatment by increasing the humidity.

    I personally have used a similar oven heating method to ensure that bedbugs were not viable in clothing or other objects after traveling.

    REFERENCE
    The Effects of Temperature and Relative Humidity on the Viability of the SARS Coronavirus
    K. H. Chan, J. S. Malik Peiris, S. Y. Lam, L. L. M. Poon, K. Y. Yuen, and W. H. Seto
    Department of Microbiology, The University of Hong Kong, Queen Mary Hospital, Pokfulam, Hong Kong
    Correspondence should be addressed to K. H. Chan, chankh2@hkucc.hku.hk
    Received 25 November 2010; Revised 31 July 2011; Accepted 31 July 2011
    Academic Editor: Alain Kohl
    here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3265313/
    CONFLICT OF INTEREST: None Reported
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    Two-tiered sterilization
    Ellard Hunting, PhD - (Microbial ecology) | University of Bristol, UK
    Since this concerns protective equipment, I consider the use of ethanol too risky as it is volatile and not effective in the long term.

    A cheaper, reliable and rapid two-tiered sterilization procedure could involve a 1% sodium chlorine treatment and subsequent chloroform fumigation step to ensure effective inactivation of both viruses and (not to be overlooked) bacteria.

    Local microbiology labs are likely equiped and able to support
    CONFLICT OF INTEREST: None Reported
    Commercial UV Box
    Greg Noel | Healthcare Manufacturing Reps
    Focus Healthcare Products UV (UltraViolet) Box was designed for hospitals by nurses to kill 99.9% of pathogens that reside on a cell phone or tablet in 55 seconds. This fits in with hospitals' hand washing protocols so that you can decontaminate your cell phones while you are washing your hands. It also has the ability to disinfect N95 isolation masks (up to 3 at a time) so that they can be reused due to the shortage of these isolation masks. You can also put in this box anything else that will fit within the space. The box is small in size so that it doesn't take up much space. You can disinfect 5 cell phones at a time. The reason this box is so effective is that it replaces disinfectant wipes which cell phone companies frown on using since they can destroy the integrity of phones. The UV that is emitted will not hurt the integrity of the phones and so far has been approved by companies like SpectraLink which is a huge supplier of phones to the healthcare industry. The UV Box uses reflective technology so that the UV encapsulates the entire units that are placed in it.
    CONFLICT OF INTEREST: None Reported
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    PPE Regulatory and Cargo Clearance Waivers to Expedite International Supplier Access
    Gregory Leon, JD | Development Specialist
    Relevant regulatory agencies could issue emergency blanket waivers to permit expedited PPE importation from overseas. Currently we are finding that many producers are hesitant to approach the US market due to concerns over: regulatory and certification hurdles, identifying distribution networks, and cargo clearance processes. In this period of clear national need, waivers could help open the door for immediate needs and restocking. In addition, expanding the supply channel would bring the supply-demand equilibrium to a less inflated price point for many purchasing managers increasing the number of potential units purchased.

    I take the point from a previous comment
    that certifications for N95 are not always comparable across certifying bodies. However, shields, gowns, shrowds, sharps containers, gloves, surgical masks, shoe covers, etc... all frequently interchangeable from country to country need not be held up due to regulatory hurdles. A simple authorizing letter from regulators could help open the door for a flood of supplies. The alternative is bandanas, 2L soda bottle shields, and reusing garments to defend against this scourge.
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    Coffee Filter Mask
    Ricardo Carbajal, Pediatriacian, MD, PhD | Pediatric Emergency Department. Armand Trousseau Hospital. Sorbone Université Médecine. 26 Av du Dr Netter. 75012 Paris, France
    While waiting for a massive increase of face mask manufacturing by companies during this COVID-19 outbreak, one possibility to increase the supply of these personnel protective equipment is to manufacture some at home using two coffee filters.

    Put one filter in the other, fold the edge of the inner filter on that of the outside, glue the edges with an adhesive tape, make two small holes on the lateral extremities to put rubber bands which will be attached or stapled and it's done.


    I've published a picture of the materials on https://ricardocarbajal6.wixsite.com/facemask
    CONFLICT OF INTEREST: None Reported
    Reuse and Steam Treatment
    Timea Hodics, MD |
    Hoarding N95 masks in the community is due to fear of catching the disease and resale for exorbitant prices.

    The public should be educated on easy ways of sanitizing their facemask using

    1) Time- 3 masks used one per day then the 4th day the first mask again.
    2) UV machines or heat with exact instructions.
    3) Steam cleaners (steaming iron) might also work.

    Once people are sufficiently reassured that they can be safe with these procedures they can donate or sell the rest at regular price to hospitals.

    Price gougers need to
    be warned to donate the supplies or sell at pre-COVID prices till 'x' date to medical centers, after which they would be prosecuted, and any supplies confiscated.

    A simple, safe measure that the public can try at home to treat the viral infection should not be discouraged, unless there is evidence that they do not work: hot steam inhalation at the first sign of a cold or sore throat has not been studied to my knowledge for COVID19. The SARS-CoV-2 virus is heat sensitive, and the steam may help clear respiratory secretions. (In my anecdotal experience 2-3 times/day 30 minutes hot steam inhalation might be needed, negative studies often used smaller doses in common cold.) If this is even mildly effective, this could ease some of the pressure on health facilities. If it does not help, no harm was done.
    CONFLICT OF INTEREST: None Reported
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    Public Health - Credit Card Reader Cleanings
    Dennis M, BSChE, BSME | Retired Chemical Engineer (a category you don't have in your list of occupations, but should; engineers are trained to solve problems!)
    Place alcohol wipes or an alcohol and hydrogen peroxide washrag near each cash register chip card reader. Hundreds of cards go through those things daily from hundreds of different hands the implication is obvious. Check-out clerks could have a spray bottle with ethyl or isopropyl alcohol (preferably 90%) mixed with a few ounces of hydrogen peroxide to re-wet the towels as the alcohol evaporates.

    Customers should be advised to use the swipe function of the card where those readers are still available -- they are less secure from theft, but more easily cleaned with computer compressed air
    which would also lower the temperature and hopefully freeze any virus.

    Every item required is available in any grocery or pharmacy -- simple, fast, and certainly more effective than doing nothing about the possible contamination from credit/debit cards.
    CONFLICT OF INTEREST: None Reported
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    Ski Buff as a Facemask Alternative
    Carol Vassar, M.D. | UVM retired community faculty
    If a hospital is at the bandana or scarf stage, ski buffs have great potential.

    The first video shows a single thickness of a ski buff fabric (by Turtle Fur but quite thin as you can see). The buff is about 2 inches from the mirror. The plant mister nozzle is about 3 inches from the fabric. None of the spray reaches the mirror. The second spray shows the quantity of water in one spray and a sense of the force of the spray.

    In the second video, the mister is held 3
    feet, give or take and couple of inches, from the mirror. You can get a sense of the fineness and spread of the spray and see what reaches the mirror 3 feet away. The paper is a page from the NEJM. The lower case letters are approx 2 mm. The smaller drops are less than 1/4 of a letter so < 500 microns which is still quite large but none of the water passed through the fabric when the nozzle was just a few inches away.

    The buff is quite comfortable even worn for several hours (as in skiing). A metal strip would be needed for a good seal at the nose as on a standard surgical mask. A cotton ball on either side was adequate. There is no side to be open. The buff is long enough to rest on the upper chest. Even doubled over it can reach the chest on smaller adults. A string, ribbon, etc could gather the lower more snuggly to the neck if needed. It is washable.

    I don't know what the fabric is but making the buff the fabric is available is simply one seam length of the bolt or strip of fabric then cutting tubes of the desired length. So manufacturing or sewing at home should take very little time.

    Carol Vassar, M.D. retired
    Internal Medicine
    Montpelier, VT
    CONFLICT OF INTEREST: None Reported
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    Sterilization with Ethylene Oxide (EtO)
    Nicolas Foin, PhD | NHRIS
    EtO is typically used for sterilising medical devices because it gets rid of everything including viruses without damaging products. See for example sterilization method here on these masks:
    https://www.berner-safety.de/sterile_facemask_ffp3_w_o_valve_en_1617.html

    There are many facilities capable of doing EtO sterilization. There may be simpler method but EtO is commonly used.

    Thanks JAMA for the initiative ! Need to prevent shortages and keep hospital staff protected.
    CONFLICT OF INTEREST: None Reported
    Spirit Gum to Seal Sides of ASTM Level 3 masks
    Randall jones, DMD | Private Dentist, former engineer
    Spirit Gum is normally used to afix theatrical facial prosthetics to the facial skin. There are various formulations, and many are too thin, but a sufficiently thick/viscous Spirit Gum could be used at the lateral edges of a typical 'surgical mask' to gain closure and dramatically reduce airflow around the mask edges.

    While it is not as elegant as many of the solutions being proposed here, this kind of concept may yield a fairly 'tight' fit without all the technical fitting needed for a typical N95 mask. Clean the skin, paint it on, dry for a few seconds,
    press, and the user may get 5+ hours on a single mask... add to that one of the surgical drape cover-masks as a 'sacrificial wet-barrier' per-patient and the underlying ASTM Level 3 has a 0.4 micron filter capability, but now with FAR less leakage. Not ideal, but far better than no seal at all.

    With the help of the manufacturer(s), a simple tweak to the viscosity (or maybe a choice of a more optimal off-the-shelf product) and this stuff is available in large quantities to act as a fill-i solution while better, longer-term solutions are found.

    We all want the long-term, ideal solution. But right now, we need some workarounds that allow appropriate applications of ASTM Level3's with improved safety for the user.

    Does anyone want to help me create a highspeed dental handpiece which does not generate a massive aerosol? Until we do, dentistry may be on an indefinite hold.
    CONFLICT OF INTEREST: None Reported
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    Use of direct UV-C in Filter Form Factor
    Randall jones, DMD, former engineer | Dentist
    UV-C disables enveloped viruses... well-accepted science. If there is enough 'dwell-time' for air passing through an intense UV-C light field, actual particulate filtration becomes moot.

    Imagine a single-can 'filter cartridge' containing a strong UV-C light source. Air passage should NOT be directly over the UV-C source, as many of them produce ozone. But if the light source was wrapped with a multi-pass helix of UV-clear tubing (back and forth along the long axis) then the 'room air' would have sufficient time at a VERY close radius to fully deactivate all bacteria, mold/fungi and viral components, AND at a
    low inhalation pressure.

    Backing up the UVC should be a carbon filter, but this system could last for hours/days, and is limited by battery charge (2000 mAhr is easy to pack around) and the carbon filter lifespan, which can be very long.
    Since most current UV-C light sources are designed to run off AC, a small DC-to-AC adapter would be the expeditious way to go, and is dead-simple project for any 3rd year EE student. The PCB would be cheap and could be ready in 72 hours, stuffed and soldered. The airhose end of the filter could be connected to any standard cartridge facemask.

    This is not rocket science. We may just need to stop thinking about the micron-size of the filter.
    CONFLICT OF INTEREST: None Reported
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    Posterior Throat Swabbing and WeChat Contact Tracing
    li xiong, MD | The Second Xiangya Hospital, Central South University
    We developed a posterior approach to throat swab sampling using a mirror using the following technique:

    (1) Prepare PPE and environment properly according to the risk assessment of pathogen infectivity from examinee in an airy room, with the wind direction from operator to examinee;
    (2) Prepare light source, light reflector (such as mirror), and material for traditional throat swab sampling;
    (3) Stand behind the examinee. Adjust the position of light source and mirror; (4) Instruct the examinee to open mouth. See the oropharynx by the mirror. Use one hand to depress the tongue with a tongue blade
    bypassing one side of examinee. Use another hand to swab bypassing another side of examinee.
    The technique is illustrated in several videos (1,2). 

    We also are developing a simple and cost-effective strategy for contact tracing based on digital-data and social media, and we've correspondingly developed a WeChat Mini Program “Xiangya-Renjie anti-COVID-19 system” and a paired English version App for international use. This Mini Program or App enables accurate location and tracking of sources of infection in the population and protection of the majority of susceptible individuals by collecting users’ volunteered WeChat activities and spatiotemporal trajectory data over the past 14 days to generate an updated space-time QR code as state identification, and calculating a dynamic spatiotemporal risk index to quantify the real-time accumulative exposure risk for each user. Concerns about data security and personal privacy could be addressed by transcoding and block chain technology.

    To join the protective network of Xiangya-Renjie anti-COVID-19 system, download the App at this link:
    https://app.rjet.xyz/app_downlod/index_en.html or login to the WeChat Mini Program by scanning the QR code showed in this website: https://mp.weixin.qq.com/s/dQQQR7L_tIm4RN0TdJR4qA

    Latest information about our WeChat Mini Program or App “Xiangya-Renjie anti-COVID-19 system” will be updated in the WeChat official account “General Surgical Online” which can be visited in the website above. We are developing multilingual version of Mini Program and App to help more people.

    REFERENCES

    1. https://youtu.be/uCFYzJowrfk
    2. http://nanomedicine.csu.edu.cn/info/1034/1205.htm
    CONFLICT OF INTEREST: None Reported
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    Negative Pressure Trailer
    Paul Hartley, MD | Internist Private Practice
    Our local hospital in western Pennsylvania obtained a trailer from the Pennsylvania Department of Health. Our facilities guys retrofitted it for negative pressure. We are directing all non-severe patients with respiratory symptoms to this trailer.This should make PPE more available and perhaps lessen the number of health care workers who need it
    CONFLICT OF INTEREST: None Reported
    Convert BiPAP Machines to Ventilators
    Ian Joffe, MD, FACC | Penn Presbyterian Medical Center
    Israel is exploring the idea of converting BiPAP machines to ventilators. There are millions of BiPAP devices in the USA. I would appreciate readers' comments on the feasibility and technical considerations.
    CONFLICT OF INTEREST: None Reported
    Home made masks simulating N 95 respirators
    Snigdha Bellapukonda, MD DNB | All India Institute of Medical Sciences, Bhubaneswar, India
    Home-made masks simulating N95 masks with four layers- two outer layers of polypropylene, middle layer of polyester and inner layer of polypropylene may prove to be very useful. This mask can be made at home with old clothes of similar material in very less time. They may be disposed after use. They are fluid resistant to a  certain extent. At least for lower-risk health care workers, this mask may spare PPE supplies for higher-risk workers. Illustration at https://youtu.be/9XF_5NFDES4
    CONFLICT OF INTEREST: None Reported
    Use Heaters Used to Kill Bedbugs
    Kevin Johnson, BSEE, MBA | Unaffiliated
    Heat at 56°C (133 °F) kills the SARS coronavirus (not SARS-CoV-2/Covid-19) at around 10,000 units per 15 min." (1)

    Hospitals could heat a hospital bathroom or closet, or even a full room, to, say, 120-130 °F using room heaters that are used to kill bed bugs at those temps. These heaters can be purchased, or rented locally, e.g. for $100 per day, or ask them to them set up. (2)

    Put laundry racks in the room and space out PPE (masks, goggles, gowns, etc.) on the racks so that they quickly reach temperature. A full hospital room could
    be heated, but that would require power cords connected to outlets on three separate 15-amp circuits to be connected to the heater. Heating a bathroom or closet may require cords connected to just two circuits.

    IMPORTANT: Avoid setting off the sprinkler system. Keep sprinkler head temps below their activation temp, which typically in the U.S. depends on the glass bulb color in the sprinkler head (3). 

    They'll have to determine heating time and temp they're comfortable with, or locate data or advice on the persistence of SARS viruses at 120-130 °F. Several hours seems reasonable offhand. The first table at (4) summarizes persistence of some coronaviruses at **room** temps. At room temps "stability of SARS-CoV-2 was similar to that of SARS-CoV-1" (5) 

    1. https://who.int/csr/sars/survival_2003_05_04/en/
    2. https://www.debugyourbed.com/ne-bedbugheaterrental/
    3. https://www.archtoolbox.com/materials-systems/fire-supression/sprinklerheadtypes.html
    4. https://journalofhospitalinfection.com/article/S0195-6701(20)30046-3/fulltext#sec3.1
    5. https://www.nejm.org/doi/10.1056/NEJMc2004973.
    CONFLICT OF INTEREST: None Reported
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    iIodine
    Ilora Finlay, MB,BS | Cardiff University
    This thread provides very important research ideas that may save clinicians lives.

    An old tool in managing infection is iodine - Derry described its use in influenza (1).

    Sometimes we ignore history at our peril.

    Recycling 'disposable' PPE will be essential and simple measures may make the difference between some protection and none. Could Lugol's iodine sprayed onto masks be added to the list of things to be urgently evaluated to see if it decreases the COVID-19 viral load ?

    REFERENCE

     1. Derry, D.: Iodine: the Forgotten Weapon Against Influenza Viruses Thyroid
    Science 4(9):R1-5, 2009.
    CONFLICT OF INTEREST: None Reported
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    Zinc-oxide (ZnO)-impregnated Textiles
    Howard David Sterling, LLB | AlphatauMedical
    SonoviaTech.com in Israel is manufacturing zinc-oxide (ZnO)- impregnated textiles that in vitro and in clinical trials are shown to kill all bacteria, even MRSA, and materially decrease nosocomial (hospital associated) infections. 

    REFERENCE

    1. https://www.youtube.com/watch?time_continue=2&v=lriyFTgimYI
    CONFLICT OF INTEREST: I am strategically helping SonoviaTech.com
    Agricultural Supplies and Repurposing
    L Olson, PA-C |
    ● Reusable solutions: elastomeric respirators are a good reusable solution as discussed above. Agricultural industries (and institutions like Ag colleges) may be able to donate extra stocks of elastomeric respirators that they use for pesticide applications etc. (Ag industries may also be a good source for other useful respiratory protective equipment including N95 masks).

    ● Disposable solutions: a medical equipment engineer would need to weigh in on the feasibility of this idea
    - for immediate needs, are currently available materials which filter at least 95% of particles down to 0.3 um (the same as N95 masks), such
    as certain Qualitative-Filter-Papers, suitable for re- purposing into disposable covers or lining for added protection in existing non-N95 masks? (Even HEPA vacuum bags, if their filtration is of high quality, might warrant consideration for urgent situations - perhaps they could be cut into covers or liners or sewn into disposable masks? Sounds absurd - but better than cloth bandanas which have reportedly been used for protection.)
    - for future needs, IF these materials have potential, their manufacturers could represent important additional supply chains provided they can modify their production to the specifications of medical PPE.
    CONFLICT OF INTEREST: None Reported
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    Missed Opportunities for Timely Discontinuation of Isolation Precautions in Routine Care
    Rebecca Grout, MD | Cincinnati Children's Hospital Medical Center
    One area for improvement we can all work towards: discontinuing PPE orders on time. Even before the COVID-19 pandemic, as a pediatric hospitalist I have witnessed many patients being kept in isolation precautions for days, if not their entire hospitalization, despite some disease-specific guidelines at my institution recommending PPE only until appropriate therapy has been administered for 24 hours.

    Some routine hospital conditions for which I see PPE inappropriately continued at my institution:

    1. Community acquired bacterial pneumonia. Droplet precautions (mask and eye protection) can be discontinued after 24 hours of appropriate therapy, which I interpret
    to mean systemic antibiotics. Even is the child is still inpatient for 2 more days weaning supplemental oxygen, Standard Precautions are the only precautions you need after 24 hours in routine cases.

    2. Influenza. Droplet precautions (mask and eye protection) can be discontinued after 24 hours of appropriate therapy (ie, Tamiflu).

    3. Cellulitis. Assuming the affected area is not draining and can be adequately covered, and assuming staff wear gloves when touching the infected area and wash their hands, contact precautions are not necessary even for presumed MRSA.

    Bottom line: Know your institution’s and the CDC’s isolation precautions guidelines and apply them. Don’t forget about discontinuing orders. A little extra thought each day on rounds, or when writing the initial isolation precautions orders could go a long way to saving PPE supplies. Each timely discontinuation could save 2 days’ worth of precautions for each patient with these 3 common conditions. We can engage our nursing and ancillary staff colleagues to help us with this task.

    Furthermore, we should not underestimate the value of Standard Precautions, by which I mean hand washing, device (cell phone, stethoscope, ID badge) washing, and environmental cleaning measures. These are meaningful precautionary measures too.

    - Rebecca Steuart, MD
    CONFLICT OF INTEREST: None Reported
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    UV Sterilization of PPE
    Amitava Gupta, M.Sc., PhD |
    I recommend short wavelength UV sterilization of PPEs in a moist environment. A commercially available low pressure Hg arc lamp emitting radiation at 257 nm is an excellent sterilizer. However, direct exposure of PPEs to low pressure Hg arc lamps may not be effective since the radiation is easily blocked and all parts of the PPE may not receive an effective dose of radiation. To solve this problem, I am proposing that the PPE be initially washed in 30% H2O2 solution as a first step (immersion for 5 minutes in a stirred bath), then exposed to 257 nm radiation from a low pressure lamp. UV radiation will generate hydroxyl radicals from H2O2 which are also excellent sterilizing agents.
    CONFLICT OF INTEREST: None Reported
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    Modify Full Face CPAP Masks and Add Inline Outlet filters, "3 sided tape" to create a vent valve
    Daniel Lalla, Faculty Lecturer | McGill Family Medicine, Dialogue Technologies
    My idea is simple:
    - Take full face CPAP mask and strap on tight There's tons of old ones you can ask people to donate
    - Add an inline filter to the 'intake' - they sell in bulk for <$5
    - Problem is the vented area that vents air out into the room (air can come in)
    - Cover the vented area of the mask with a sturdy piece of plastic and tape around all sides leaving one side 'free'
    - This is like a 3-sided tape technique used in the field for sucking chest wounds
    - This
    only allows air OUT through the perforated/vented area of the mask, not in

    You can 3D design and print a 'box' filter to fit on the mask. Just design it in two halves that can be 'locked' together. That way you can just put in a small piece of filter material and they could be used for hours. Uses a fraction of filter material. Would need testing though and an N95 type material

    I've tried to illustrate the idea at https://www.dropbox.com/s/ct7of319jj4kgha/Idea%20to%20provide%20filtered%20air%20to%20Healthcare%20professionals.pdf?dl=0

    Dr. Daniel Lalla - Canada
    daniel_lalla@hotmail.com
    CONFLICT OF INTEREST: None Reported
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    Approach to PPE Resource Stewardship
    Stephen Parodi, MD | Kaiser Permanente
    1. Minimize patient-provider contacts: Maximize the use of telehealth for outpatients including those with cold/cough symptoms. Use of remote monitoring of inpatients can reduce the need for ingress/egress for hospital rooms.

    2. Cancellation of elective surgery: Reduces gown, glove and mask use in addition to intubation/extubation. Screen remaining surgical patients for cold/cough prior to operating to reduce the need for N95 respirators.

    3. Minimize points of entry: Reduce the foot traffic in a clinic/office by screening patients for cold/cough and triaging to a sick area for further evaluation.

    4. Designate areas for
    cold/cough evaluation: Define an area for patients with cold/cough so healthcare workers only need to change gloves and wash their hands in between patients while maintaining the same PPE unless otherwise soiled. If existing infrastructure won't support that approach, consider alternative sites including tents.

    5. Drive through testing: A healthcare worker can use the same PPE other than gloves in between patients while obtaining nasopharyngeal samples.

    6. Preserve the use of PPE through reuse and extended use: First determine whether you might have a shortage of N95 Respirators, PAPRs, CAPRs, surgical masks, isolation masks, gowns, gloves, goggles, and face shields. Determine the need for potential preservation of PPE based on current supply/days of inventory on hand, current use rate, anticipated duration of time before resupply, and the potential for a surge of need based on the status of the epidemic curve in a given locale. CDC has guidance regarding reuse of N95 respirators, isolation masks, and face shields. Extended use with N-95 respirators, isolation/surgical masks, and face shields is appropriate when caring for cohorted patients with COVID-19.

    7. Use of alternative supplies: For example, if goggles and/or face shields are no longer available, the use of safety goggles are a potential alternative.

    8. Cleaning of PPE: Cleaning of goggles and face shields in between use with appropriate processes can also preserve PPE.

    9. Use of expired N95 Respirators: Some respirators from manufacturers and the strategic national stockpile may be expired. CDC has issued guidance for the use of expired N95 respirators in the setting of resource constraints. These respirators should be checked for integrity and seal prior to use.

    10. Secure the PPE: Theft of PPE is a concern in resource constrained times. Engaging with management, staff, and security to balance both accessibility and security of PPE is important.

    11. PPE "Strike Teams": If a site is unable to designate a specific area to triage cold/cough patients for evaluation, consider having specific trained personnel who can perform the cold/cough evaluations with PPE which will minimize the number of individuals that require specialized training and reduce the potential for PPE loss through suboptimal use.

    All of these actions require communication to physicians and staff about why these measures are being taken and how they will be done with their safety as the first priority. Equally paramount, is to provide the training and instruction necessary to appropriately reuse and clean PPE.
    CONFLICT OF INTEREST: None Reported
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    Used for years in Mission Hospitals
    Jerome Koleski, MD | University of Arizona College of Medicine
    1. Gloves - Wash, air dry, powder and autoclave gloves to get up to 4 uses per glove.
    2. Save O2 - oxygen concentrators deliver up to 5 LMP. We will be running short of oxygen very soon. attaching 2 - 3 concentrators in parallel can give more than 5 LPM.
    3. Re-sterilize venti masks, air tubing, nasal cannulas, Foleys and NGT as above - wash the tubing in antiseptic solution, air dry on a drying rack, and autoclave the tubing - doubling to tripling the equipment inventory
    4. Make CPAP - one end of a nasal cannula to
    the patient - the other end into a jar of water. The depth of the free end below the water line is the centimeters of H2O pressure. (from Improvised Medicine: Providing Care in Extreme Environments. Kenneth Iserson*)
    5. More autoclaves can be borrowed/ rented from dentists and surgery centers which should not be doing anything but emergent procedures.

    *All hospitals should have a copy of Iserson's book, Improvised Medicine: Providing Care in Extreme Environments. I have no interest other than I own a copy of the book and have used it.

    Jerry Koleski, MD
    Co-Director of Global Health Programs
    University of Arizona College of Medicine
    CONFLICT OF INTEREST: None Reported
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    Conserving PPE in the COVID-19 Crisis
    John Deacon |
    I have read ideas here about using an ozone compressor, but could not find ideas of how to sterilize large quantities of PPE simultaneously.

    Restoration companies such as Servpro use ozone machines inside storage pods to remove mold and smoke damage odors. This would also work for restoration of soiled PPE and other items needed for reuse due to supply shortages.

    If this idea has already been suggested, I apologize, but this is the time for humility.
    CONFLICT OF INTEREST: None Reported
    Expansion on Snorkel Masks
    Eric Terry, PhD Biochem and MolBio | Washington University in St Louis
    I've run this down a bit more trying to put something together that can be relatively easily assembled from off the shelf parts from Amazon. A number of the snorkel masks I've looked at have a one way valve in the mouth region in addition to a two part air circulation system that goes through the snorkel apparatus. I've figured out a simple coupling system that allows me to attach a hose to the mask on one end, and the output of a semi portable room HEPA filter on the other. The apparatus seemed to be able to maintain positive pressure from the output of the powered filter. The room HEPA filter, although bulky is light and I was easily able to carry it in a backpack. I'm also waiting for a shipment of a smaller portable power filter, as well at looking at additional modifications that may make it easier to build/deploy/produce at scale.
    CONFLICT OF INTEREST: None Reported
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    More on Snorkel Gear for a Low-Cost Faceshield/Respirator
    Derek Farley, D.O. | Methodist McKinney Hospital, McKinney, TX and MedcoER Frisco and Plano, TX
    Out of desperation, and recognizing a lack of eye protection, I thought about what I have around the house that could be used when I go to intubate a COVID-19 patient. I have a snorkel and scuba mask, so I placed two N95 masks together at the snorkel intake, taping them together with Microfoam tape to make an airtight seal. This would allow for filtration of air with the scuba mask, as a regular N95 mask could not be used with the scuba mask. I presented this on my Facebook page and Cybil True, CRNA, recommended using a full-face mask/snorkel combination. I bought one on Amazon for $26, and I’m awaiting its arrival in 5 days. She was able to rig up a similar N95 at the intake, and said it worked great.

    I anticipate using this and then utilizing some kind of aerosolized antiviral antiseptic afterwards to at least decrease contact spread at removal. This is posted on my Facebook page. If I could post pictures here I would. If you need more information please contact me either via Facebook or my cell 469-358-3134, email derek.farleyfm@icloud.com
    CONFLICT OF INTEREST: None Reported
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    Demand and Supply Management of Personal Protective Equipment in Taiwan
    Chih-Yuan Lin, M.D. (Neurologist), M.Sc. | Department of Neurology, Taipei City Hospital, Taipei, Taiwan
    Dear Editor,

    We have read with interest the article 'Conserving Supply of Personal Protective Equipment—A Call for Ideas' by the editors of JAMA (Bauchner et al.). We would like to provide commentary on two ideas in relation to this article that have come from our daily practice in Taipei City Hospital, Taiwan.

    1. Taiwan's setting
    Taiwan’s National Health Insurance (NHI) scheme, built on the core concepts of mutual assistance and risk-sharing, is a state-organized compulsory social insurance plan launched in 1995, which now has a coverage of 99.6% of the population in Taiwan. It is based on
    the principle of contractual solidarity: everyone makes a fair financial contribution to the NHI, which in return guarantees equal access to health services for all. We have learned valuable lessons from the catastrophic 2003 SARS epidemic and subsequently established a comprehensive rapid response system (1). The Taiwan Centers for Disease Control (CDC) activated the National Health Command Center (NHCC) as the designated commander for disaster management.

    2. Managing Demand-Risk stratifying for PPE use
    We have followed the conceptual framework proposed by Kocher et al. for the categorization, designation, and regionalization for coronavirus disease 2019 (COVID-19) infection emergency care (2). According to past experience in Taiwan, we have risk-stratified suspicious cases based on their clinical symptoms, occupation, geographical travel exposure history, contact with a definite case history, and any cluster history in the 14 days prior (3). To match patient needs, we have designated 167 primary care clinics/hospitals for screening and initial testing of suspected cases and categorized 50 hospitals to monitor and care for highly suspected or diagnosed cases in 6 regionalized Communicable Disease Control Medical Networks (1). 

    3. Managing Supply-Solidarity as the core principle
    In the fight against the COVID-19 pandemic, we so far only have supportive treatment that tests our local, regional, and global health care system. Aside from a vaccine that is still months to years away, bioethics may be a crucial principle in facing this unique global catastrophic risk. Contemporary bioethics categorizes solidarity as interpersonal, group practices, and contractual legal levels (4). In Taiwan, the NHCC took a contractual legal role in the allocation and distribution of PPE resources (such as facemasks, N95 respirators, gowns, and alcohol). On the group practice level, Taiwan and the United States are stepping up efforts by sharing best practices and cooperating on the research and development of rapid tests as well as the research and production of vaccines and medicines. On the interpersonal level, Taiwanese have launched the “I am okay – facemasks are left for medical staff and you first” campaign, and every individual minimizes the risk by mitigating exposure to the pathogen and eradicating any possible routes of infection.

    References:
    1. Kao H-Y, Ko H-Y, Guo P, et al. Taiwan's Experience in Hospital Preparedness and Response for Emerging Infectious Diseases. Health Security 2017;15(2):175-84. doi: 10.1089/hs.2016.0105
    2. Kocher KE, Sklar DP, Mehrotra A, et al. Categorization, designation, and regionalization of emergency care: definitions, a conceptual framework, and future challenges. Acad Emerg Med 2010;17(12):1306-11. doi: 10.1111/j.1553-2712.2010.00932.x [published Online First: 2010/12/03]
    3. Wang CJ, Ng CY, Brook RH. Response to COVID-19 in Taiwan: Big Data Analytics, New Technology, and Proactive Testing. JAMA 2020
    4. Prainsack B, Buyx A. Solidar
    CONFLICT OF INTEREST: None Reported
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    Put More responsibility on Patients & their family because doctors are going to be super stressed & need their help
    Stephanie Wong, Business | Citizen
    American patients can and want to help during the pandemic. Further, many will have the time/energy/and ability to do their part to keep medical staff as safe as possible during their hospital visit. Medical providers should begin educating future patients and families on procedures they need to follow to keep medical staff safe. For example:

    1) Ask patients and accompanying family members to come wearing their own mask/item to prevent spread of airborne germs. Many patients and their family have masks from their own work place. They can put brown bags/pillow cases/scarves/ski masks/painters
    head covered mask/muslim scarf &face wrapping hijabs, etc over their heads before coming into waiting room.

    2) Ask patients to disinfect seats they sit on, keep their distance from doctors and avoid breathing/coughing on them. Cover the patient's face and bodies with heavy thing until you actually need to remove it for access and don't worry about seeming rude.

    3) Ask patients and helpers to bring a 2nd change of clothing so they can be sprayed with chlorine/water/disinfectant before seeing the doctor. Before going home they should have their own 2nd change of clothing.

    4) Have patients wait in a heated room capable of minimizing strength of SARS-CoV-2. Have patients stand behind clearly marked lines to keep their distance from staff at varying intervals.

    5) Else, if you need an infectious spray/spit shield, hobby lobby sells wide sheets of thick clear plastic for furniture covers that can be duct taped onto any rounded surface that can be placed on the head.
    CONFLICT OF INTEREST: None Reported
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    Use of Blockchain
    Sareer Zia, MD, MBA | SIH
    Blockchain technology can be used to manage supply chain. It will also improve the transparency and reduce the uncertainty around availability of these limited resources. It will tremendously help in proper allocation of PPEs and other medical supplies and will prevent the concentration of these finite resources in certain areas and will prioritize their allocation to places where they are needed the most.

    While there are already great ideas flowing here, some other suggestions if they have not been considered in some institutions include:

    - Devising a policy around limiting the number of visitors/family/friends/relatives of COVID-19 patients admitted
    in hospital.

    - Engineering a workflow where staff (care coordination team, dietitian, pharmacy, diabetic educator, CHF nurse, navigators from various service lines) contact hospitalized COVID-19 patients via telephone or telemedicine instead of going into their rooms.

    Thank you and All the Best!
    CONFLICT OF INTEREST: None Reported
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    Hypochlorous acid (HClO) is recommended for hand washing and disinfecting the environment
    Oliver Ho, Ph.D. Candidate | Institute of Health and Welfare Policy, School of Medicine, National Yang-Ming University, Taipei, Taiwan
    A study published by Allison E. Aiello in 2012 (1) suggested that in the early stages of an influenza outbreak, the government should promote anti-epidemic measures to wear masks and maintain hand hygiene. The community infection caused by the COVID-19 virus caused panic among the population, which caused insufficient resources for masks and disinfectant supplies.

    In Japan, research on the use of hypochlorous acid was carried out 20 years ago (2). Hypochlorous acid has a good effect in disinfection. It is not as toxic as bleach and it is not as prone to fire as alcohol. In Japan it
    is also used for medical, food, and workplace disinfection, including hand washing or surgery, and even as a  mouthwash (2, 3). However, too high a concentration may cause damage to the skin, and too low a concentration may lack bactericidal power. If hypochlorous acid water is used on the skin, like alcohol, excessive use may cause skin allergies. The use of hypochlorous acid in environmental disinfection should be avoided on iron and rust. Hypochlorous water for environmental disinfection is 100 ppm, If sprayed directly on the hands, 30-50 ppm is recommended to avoid excessive damage to the skin. To avoid skin irritation, rinse with water after use.

    References:
    1. Aiello, AE, Perez, V., Coulborn, RM, Davis, BM, Uddin, M., & Monto, AS (2012). Facemasks, hand hygiene, and influenza among young adults: a randomized intervention trial. PloS one, 7 (1).

    2. OKUBO, K., URAKAMI, H., & TAMURA, A. (1999). Cytotoxicity and microbicidal activity of electrolyzed strong acid water and acidic hypochlorite solution under isotonic conditions. Journal of Infectious Diseases, 73 (10).

    3. Ono Tomoko. (2012). Examples of application of various germ bactericidal effects of weakly acidic hypoglycinic acid aqueous solution. Journal of the Japan Society of Pharmaceutical Industry = Journal of the Brewing Society of Japan, 107 (2), 100-109.
    CONFLICT OF INTEREST: None Reported
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    Recovered Patient Volunteers, Maybe Dish Gloves?
    Francesca Decker, M.D., M.P.H. | Non-practicing
    There are so many outstanding ideas here. Thank you.

    Please put out a call for ideas for expanding and alternatives to ventilator production and utility.

    My suggestions:

    - Using immune workers in COVID wings and isolation units is a great idea. As we get clarity as to the risk of reinfection, we could ask recovered COVID patients if they are willing to volunteer or be paid to do this, knowing the risk. We need State governments may be able to help if pay is involved. They could bring in food and assist with
    other non-medical needs, and maybe be trained to read monitors or attain vital signs.

    - If the situation is dire, dishwashing gloves could be used in the absence of medical gloves. Note that Malaysia is on lockdown and they make most gloves for the world.
    CONFLICT OF INTEREST: None Reported
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    Fashion and Ferrari - Mater Artium Necessitas
    Claudio Bernucci, Chief of Neurosurgery Unit | Pope John XXIII Hospital, Bergamo, Italy
    Italy is currently the most plagued European country by the relentless COVID-19 spreading. This epidemic is challenging the Italian Health Care System, and our country is suffering the highest worldwide infection-related mortality.

    Starting from the first two weeks of the contagion, major attention was given on the shortage of medical supply (i.e. PPE and ventilators). Since Italian citizens, as is well known, are proverbially imaginative and creative, they proposed several solutions to solve this issue.

    Few days ago, the Miroglio group (Alba, Cuneo, Italy), a multinational group with many clothing brands and one of the Europe’s major companies
    in the printed and solid dyed fabric, yarn, converted part of its production toward facial masks: thousands of orders have been processed since the official announcement (1). On the same days, Creazioni Futura (Altavilla, Vicenza, Italy) that creates professional clothing, applied its experience to develop a new kind of facial protective mask, reusable up to seventy times. A very interesting news was communicated by the notorious Ferrari company (Maranello, Italy) well-known all over the world for their stunning sport cars. On the 20th March 2020 they declared that they are ready to build mechanical ventilators (2). Who would have imagined medical devices marked with the "Cavallino" trademark?

    Other good news comes from Mirandola (Modena, Italy) where the Intersurgical, an industry specialized in respiratory production, in collaboration with the University of Bologna, developed a special airway circuit that can grant ventilatory support to two patients together while attached to the same ventilator (3).
    These difficult times are reminding us that we all can provide our contribution to overcome difficulties. As ancient Roman fathers taught us: “Mater artium necessitas” (Necessity is the mother of invention).

    References

    1. https://www.lastampa.it/cuneo/2020/03/18/news/alla-miroglio-di-alba-corsa-contro-il-tempo-per-produrre-100-mila-mascherine-al-giorno-1.38607204
    2. https://www.ilsole24ore.com/art/ferrari-e-marelli-pronte-ad-aprire-fabbriche-produzione-respiratori-AD2YKhE
    3. https://gazzettadimodena.gelocal.it/modena/cronaca/2020/03/19/news/dalla-intersurgical-di-mirandola-nuovi-ventilatori-polmonari-in-grado-di-aiutare-l-assistenza-ai-malati-1.38613466
    CONFLICT OF INTEREST: None Reported
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    Viral Superinfection Therapy (SIT) Platform Technology to Treat COVID-19
    Tibor Bakacs, M.D., Ph.D., D.Sc. | HepC, Inc
    Recently we proposed a strategy to activate antiviral defense with a harmless avian virus (IBDV vaccine strain R903/78) to treat COVID-19 (1). This innovative superinfection therapeutic (SIT) strategy could change COVID disease outcome and complement other therapeutic approaches and the development of prophylactic vaccines. SIT is based on clinical observations that dominance can alternate between two unrelated viruses in co-infected patients (e.g. in HBV/HCV co-infections). During SIT, the patient benefits from superinfection with an apathogenic dsRNA virus such as the infectious bursal disease virus (IBDV), which is a powerful activator of the interferon-dependent antiviral gene program.

    It has been
    shown very recently in another preprint manuscript that in contrast to SARS-CoV, SARS-CoV-2 is extremely sensitive to type I IFNs (2). In Vero cells, IFN alpha treatment reduces SARS-CoV-2 titers by 3-4 orders of magnitude while SARS-CoV replication is reduced only a few fold. This unique property points towards effectiveness of the IBDV R903/78 drug candidate to counter SARS-CoV-2 infection.

    An attenuated vaccine strain of IBDV was already successfully administered to resolve acute and persistent infections induced by two completely different viruses, the hepatitis B (DNA) and C (RNA) viruses (HBV/HCV) (3,4). The new drug candidate, IBDV R903/78, was re-derived by reverse genetics and preclinical data indicated that the attenuated virus is very stable and can be delivered orally. GLP toxicology studies indicated the safe dosing of rats at 400 times of human equivalent proposed doses (unpublished data). The drug candidate can be manufactured very rapidly and at very high titers. Production of several thousands of doses would take only a few weeks. The simple manufacturing processes in standard bioreactors in chemically defined medium has been developed by ProBioGen AG based on its AGE1.CR.PIX suspension cell line. The cell line is approved for manufacture of human vaccines. Titers up to 10(E10) TCID50/ml can be achieved in a 4-day process. The product is separated from cells by filtration and formulated by dilution.

    We propose the use of an orally administered R903/78 for the treatment of COVID-19 patients within the Monitored Emergency Use of Unregistered Interventions Framework (MEURI). We propose an accelerated program to treat approximately 100 patients for 1 month with 1 vial/day/1x10(E7) infectious units. The vials would be shipped to SARS-CoV-2 infected individuals to evaluate disease progression and recovery from COVID-19 before treatments of larger numbers of patients.

    REFERENCES

    1. https://www.preprints.org/manuscript/202002.0147/v3
    2. Lokugamage, K.G., Schindewolf, C., Menachery, V.D. 2020. SARS-CoV-2 sensitive to type I interferon pretreatment. bioRxiv, 2020.03.07.982264.
    3. Csatary, L.K., Telegdy, L., Gergely, P., Bodey, B., Bakacs, T. 1998. Preliminary report of a controlled trial of MTH-68/B virus vaccine treatment in acute B and C hepatitis: a phase II study. Anticancer Res 18, 1279.
    4. Csatary, L.K., Schnabel, R., Bakacs, T. 1999. Successful treatment of decompensated chronic viral hepatitis by bursal disease virus vaccine. Anticancer Res 19, 629.

    Contact information: 1012 Budapest, Miko str. 3. II. fl. 11., Hungary; Tel: +36-30-726-5122, Email: tibakacs@hepcinc.com; tiborbakacs@gmail.com, http://www.superinfectiontherapy.com/
    CONFLICT OF INTEREST: Chief Scientific Officer and Shareholder of HepC, Inc.
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    Daily Nursing-Led Transmission Based Precaution Rounds
    Stephanie Herber, MSN, RN, CCRN, CNL | Cincinnati Children's Hospital Medical Center
    A nurse conducted daily review to identify patients eligible for transmission-based precaution (TBP) discontinuation so as to conserve PPE. We found 3 common reasons patients were in unnecessary isolation:

    (1) The patient was placed in isolation because they were waiting for results to come back and precautions were not removed or adjusted to accommodate the organism/illness found.
    (2) The patient was placed in appropriate transmission-based precautions at the time of illness, however isolation was not reconsidered after the appropriate amount of time had gone by.
    (3) The ordering physician was unsure of whether the patient should
    be isolated or not, so full isolation was ordered as a protective measure.

    This process has helped reduce our unnecessary isolation use substantially.
    CONFLICT OF INTEREST: None Reported
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    Aerosol Box To Make the Patient Less Infectious
    Caroline Halverstam, MD | Albert Einstein College of Medicine
    A Taiwan anesthesiologist developed a plastic 'Aerosol Box' to contain the spread of aerosolization during endotracheal intubations (1). I think this is a good idea of “thinking outside the box” where we can come up with ideas to do things to make the patient less able to infect healthcare workers and reduce the need to use of change PPE.

    REFERENCE

    https://focustaiwan.tw/society/202003220009?fbclid=IwAR2LFvnZwAaZRtXi15KgJ3ygtif1DPnjdXtIae5KMPvlfmU5FUlwkC3VSmA
    CONFLICT OF INTEREST: None Reported
    PPE Resource Conservation, Extension, and Creation
    Destie Provenzano, MS | George Washington University Hospital
    The Biomedical Engineering and Radiation Oncology Departments at GWUH have been collaborating to come up with a series of policies to conserve and extend PPE and procedures to create new resources.

    Outpatient cases are handled through telemedicine and triage. Risk factors related to current symptoms or past behaviors (Smoking/ Prior Disease) can elevate cases to hospital admission faster. Pulse-ox applications on a smart phone are one way patients can self-report need for elevation from home care to hospital admission.

    In-patient cases can be handled by placing as much monitoring equipment as is possible outside the patient
    room to conserve PPE needed to enter the rooms, and thermal cameras are being leveraged around the hospital to detect subclinical fevers.

    The university's biomedical engineering department is currently being leveraged to prototype, fit-test, and produce reusable 3D printed masks with replaceable N95 equivalent filter cartridges. Current equipment and masks can be sterilized through re-purposed UV lights or by heat (70 degrees celsius for 30 minutes per guidance from http://www.imcclinics.com/english/index.php/news/view?id=83). Re-usable masks can be sterilized through conventional methods of bleach or alcohol wipes without damaging structural integrity. Additional N95 equivalent or higher mask source have been explored from alternate sources (like construction sites).

    Involved in this effort:

    Dr. Yuan J. Rao, M.D. Assistant Professor of Radiation Oncology

    Destie Provenzano, M.S., Doctoral Student Biomedical Engineering

    Dr. Murray H. Loew Ph.D., Department Chair and Professor Biomedical Engineering

    Dr. Sharad Goyal M.D., M.S. Director, Division of Radiation Oncology
    CONFLICT OF INTEREST: None Reported
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    Community Emergency Response Teams have thousands of N95 masks that could be repurposed
    Robert A. Lowe, MD, MPH | Oregon Health & Science University (Professor Emeritus)
    FEMA has developed a national network of trained volunteers, Community Emergency Response Teams (CERTs) (1), who have received basic training in how to assist professional responders in emergencies (earthquakes, floods, and other major disasters). In my community, and I believe in most communities, CERT volunteers have one or more N95 masks in our "go-kits." Additional N95 masks may be stored in caches around the community.

    Here in Portland, Oregon, we are collecting as many of those masks as possible to donate to medical providers. This requires good communication between leaders in the medical care system and local CERT
    leadership. I hope this partnership can be replicated elsewhere.

    REFERENCE

    1. https://www.ready.gov/cert
    CONFLICT OF INTEREST: None Reported
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    Radiate it. Just Radiate it.
    Douglas Housman, MD | Harold Leever Cancer Center
    Radiation has long been used to sterilize blood, food medical devices and even certain types of graft. This is a perfect easy system for which the infrastructure already exists. And the hardest hit locations all have access to it one way or the other.

    The ideal dose is approx 25kGy, which as a Radiation Oncologist, I will admit is a massive dose. But this is done all the time in industry. I could use a modern linear accelerator (linac), the same ones which would likely be underutilized during a burdened hospital. It would take me
    about 1-2Hr with a linac to deliver enough dose to sterilize PPE.

    The next challenge is to select the PPE to sterilize and then repackage and distribute.

    I think the highly active Cobalt and Cesium sources that are used in industry and blood banks would be best suited. They are regulated by the NRC so the government knows exactly where they all are and monitor them closely.

    There is tons of data for this. It is elegant in its simplicity, not to mention extremely cost-efficient. More efficient for the highly active sources than the linac.

    And then us Rad Oncs can feel more helpful with our limited skill set.

    Here is a primer:

    http://large.stanford.edu/courses/2018/ph241/goronzy2/

    And just a small sample of the data:

    https://bioprocessintl.com/upstream-processing/upstream-single-use-technologies/guide-to-irradiation-and-sterilization-validation-of-single-use-bioprocess-systems-183975/

    Chris Barker, MD and I were just discussing this very idea tonight. He is a brilliant, rockstar radiation oncologist at Memorial Sloan-Kettering, where we both trained.

    I hope this is helpful and useful.

    Sending you all good energy and good luck.

    Douglas Housman, MD.
    Radiation Oncologist
    CONFLICT OF INTEREST: None Reported
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    Homemade Mask From a Cotton T-shirt and Coffee Filter
    Lynn Gordon, Ph.D. | California State University, Northridge
    I have invented a no-sew face mask made from the sleeve of a men's cotton T-shirt and a coffee filter as follows:

    1) Lay the shirt flat and cut a 1-inch strip from the hem up toward the sleeve. After you get to the armpit, start to widen your border so it is about 2-inches away from the shoulder seam at the top of the shoulder. You can eyeball this and not measure.
    2) Start at the hem and cut the long strip (which is actually 2-inches wide because the fabric was doubled when you made the first cut)
    into TWO longs strips about 1-wide each. Stop at the arm pit area.
    3) Cut open the sleeve along the armpit seam. 4) Lay the mask flat, fold a coffee filter in half, and snuggle it up along the top fold.
    5) Wear glasses to snug the fabric up around the nose.

    Photos: https://www.facebook.com/lynn.gordon.98/posts/10219494434684363

    Note that this method does not limit the availability of N95 respirators and surgical masks for medical professionals in healthcare settings. Two washable masks can be made from each T-shirt. The coffee filter liner should obviously be swapped out regularly and the mask should be laundered frequently.

    An article in The Lancet, on March 20th, recommended the invention of reusable masks like this (1)

    We will post this idea online at T-shirtMask.com, but if you wish to share my photos and these directions online in some other way, I authorize you to do so. I authorize any method of free, open-source sharing and distribution with attribution.

    REFERENCE

    1. https://www.thelancet.com/…/PIIS2213-2600(20)30134…/fulltext

    *********************************
    Lynn Gordon, Ph.D.
    Professor
    Department of Elementary Education
    California State University, Northridge
    Lynn.Gordon@csun.edu
    *********************************
    CONFLICT OF INTEREST: None Reported
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    Sterilization of disposible n95/n100 masks
    Mark Fisher, MS Mechanical Engineering | Northwestern University
    I did a bit of research yesterday hoping to find an easy way to do mass sterilization of used masks. The primary filter material is non-woven polypropylene so it can't take heat, gamma or ebeam sterilization. Polypropylene has amazing chemical resistance, though. I suspect that EtO would work well and probably even a chlorine bleach vapors. I suspect that the elastic bands would need to be replaced, though. It would be a pretty simple matter to work with Stericycle or other contract sterilizers to do this (especially EtO). Alternatively, even some sort of tent arrangement could work for some thing like chlorine bleach (NOT EtO!). There would need to be some bioburden kill tests, to know the effectiveness, but I'm sure it would be better than the cloth masks some are proposing. I'm happy to help with a project like this. My email is mark@missionproddev.com.
    CONFLICT OF INTEREST: None Reported
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    Chlorine Baths for Disposable PPE
    Mark Mavity |
    Chlorine is one of the CDC's recommended methods for COVID disinfection. Using similar concentrations, collect and immerse disposable PPE for 30 minutes, then water rinse, and dry. This should allow for large quantities of disinfection using a cheap and largely available source.
    CONFLICT OF INTEREST: None Reported
    Mobile App For PPE Distribution and Prioritization
    Wei-Chiao Chang, D.Phil (Oxon) | Taipei Medical University
    An online real-time platform mobile phone app could be developed to distribute PPEs in a rapid, safe and effective way. This platform should display the requirement(s) in addition to the availability of PPEs for the at-risk groups. Furthermore, such vulnerable people should be able to register to make orders of PPEs which could be sent via Uber or other special deliveries. They can report their current health online and if they exhibit symptoms like a fever or a cough, the system can help to drive them to the nearest hospital for free. Local governments could incentivize the community to donate any PPEs by implementing policies such as tax-deductions/rebates and consumption vouchers to benefactors. The real-time app would be updated continuously to ensure that PPEs are allocated to the highest risk group at any time. With the built-in GPS, tracking of all the infected persons would be possible and this would facilitate the self-isolation of patients and provide them with care. With this idea, traffic delays could inevitably be alleviated, exposure to others minimized, and hence the risk of infection should be reduced.

    Wei-Chiao Chang D.Phil (Oxon), School of Pharmacy; Integrative Research Center in Critical Care, Wan Fang Hospital, Taipei Medical University, Taiwan

    Chun-Jen Huang, PhD, Integrative Research Center in Critical Care, Wan Fang Hospital, Taipei Medical University, Taiwan
    CONFLICT OF INTEREST: None Reported
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    Practical Sanitization of Disposable PPE
    Bob Rousseau, BS. | UC Davis
    I posted photos and details of a DIY ozone sterilizer suitable for N95 masks at xyztek.com. It can be used immediately but the intention was to have a prototype for development. It uses potassium iodide solution as an ozone exposure indicator. It does not neutralize the ozone afterwards. Ozone can be neutralized with activated charcoal. I will continue working on an ozone neutralizing feature.

    Coronavirus is killed at moderately raised temperatures (it even dies at room temperature in a few days). A cheap easy wardrobe cabinet can be built where hospital clothes and PPE can hang. It can
    be heated to a reasonable temperature such as 56C (56C has been suggested elsewhere as a good sanitizing temperature) using common PTC heaters and a fan to circulate the hot air (PTC-type for safety!). The temperature and exposure time to get desired efficacy needs to be determined (I bet some data has already been published somewhere). If I were a doctor, I would "cook" all my stuff over night.

    DIY face shields can be built much more simply than the 3D printed versions I have seen online. They can be made from 0.010" or 0.015" clear polycarbonate or similar plastic, 1" soft urethane foam, and superglue. 3/4" wide polyester Grosgrain ribbon makes an good strap.

    The "Supplied Air for PAPR" comment above gave me an idea: On an airplane, in your seat, you could hook into the air above your head, pipe it through a HEPA filter and into a mask. Airliner air may already be clean enough so you might not need the additional filter.
    CONFLICT OF INTEREST: None Reported
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    Mask production: convert industry, redistribute supplies, involve the community effectively.
    Tara Holahan, RN, BSN | Pediatric RN, 30 yrs Experience with large teaching hospital: inpatient, home care and care coordination/primary care
    1. Solicit manufacturers of HEPA filter vacuum cleaner bags to transition to N95 and ear loop face mask production.

    2. Solicit donations of, or buy masks from nail salons.

    3. Contact veterinary hospitals and university research facilities for supplies

    4. Co-ordinate with other professional groups: CDC, ANA, ADA... to provide science based guidance to community based groups to mobilize the production of home-made general purpose PPE that will have a measure of success. Maybe cutting vacuum bags down and attaching elastic ear loops?

    I am
    seeing a dangerous trend on Facebook: groups are making masks based on pleas from local ER and hospital workers. They are making cloth masks that are <3% effective once moistened by the breath of the wearer. It is a waste of time, energy and resources.

    Standard guidance would harness local communities to produce effective tools for healthcare workers.
    CONFLICT OF INTEREST: None Reported
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    Use public transit as donation drive collection mechanism?
    Joseph Chiu, None | None
    Comment form Danielle Jackson, MD MPh to ask for transit agencies to donate a portion of any of their stockpile inspired a potentially useful idea -- have a distributed donation drive where the transit system can potentially be used as mobile collection centers.

    Bus routes are often anchored to transit centers or designated route exchange terminals so that any donation can be swept to centralized collection after each run.

    Set appropriate criteria for items being donated so that it's not a waste of time/resources -- but this may help with PPE supply collection, especially with transit systems that
    provide real-time bus arrival information to minimize inconvenience.
    CONFLICT OF INTEREST: None Reported
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    Better PPE reduces the risk of sampling infection
    xiaolin zhu, Doctor of Science | Clinical Laboratory,The Second Xiangya Hospital,Central South University
    For medical staff, it is a very high risk operation to collect throat swab samples for detection of COVID-19 nucleic acid. In the process of collection, generally speaking, patients can sit or lie down, sample collectors will wear goggles and screen, but patients will cough and vomit during the collection process, so the droplets will spray on the screen of the collector, which will greatly increase chance of infection. This collector is also more likely to cause cross infection when he continues to collect samples from others.

    In order to reduce this risk, Li et al invented a disposable
    "medical anti droplet tongue pressure sampling device", which is like a plastic transparent shield with tongue pressure plate. When sampling, it can cover the patient's mouth and nose. The collector can observe the patient's throat through the transparent screen and collect samples, which can greatly reduce the spray range. For sample collector without such professional equipment, it is also very easy to make a similar device by themselves for each patient when collecting throat swabs, Just one more piece of transparent plastic can protect themselves very well. This also reduces the need for sample collectors to replace their own screens and personal protective equipment can be saved to a certain extent.

    Referrence
    [1] http://t.pae.baidu.com/s?s=bai-szxo20
    CONFLICT OF INTEREST: None Reported
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    Methods for PPE Decontamination and Reuse
    Brian Gibney, MB BCh BAO, FRCR (RCSI) | Vancouver General Hospital
    Many hospitals will face PPE shortages in the coming weeks. Shortages of N95 filtering facemask respirators (FFRs) will be most impactful, but also standard masks, gowns and plastic face shields. Stockpiling of used PPE should be commenced NOW so that they will be available for re-use after disinfection. While using a mask that another has already used may be unappealing, it is probably preferable to no mask.

    We could set up lidded buckets/ bins for USED, UN-SOILED N95 FFRs, standard masks, gowns and face shields in some areas in the department, then seal and label bags with the
    date. PPE could even be directly inspected for soiling, with discarding of soiled items, and placement of individual items in separate labelled ziplock bags.

    In the event of a complete PPE shortage, once these bags have been sealed for approx. 1 week, they could likely be considered "COVID-19" free. The longer they are stored, the greater the confidence of no COVID-19 infectious risk and if we (hopefully) never need them they can be dumped.

    In addition, various disinfection techniques have been tested for these PPE. There will soon be guidelines on practical, effective disinfection solutions which we can apply to the stockpile of PPE for recycling. Nebraska Medical Centre has already instituted a UV light decontamination and reuse protocol for N95 FFRs, which they have made available

    An ongoing literature revieww is available here which will be submitted for peer review as soon as it is completed:

    https://docs.google.com/document/d/1KKfiG8mGuaFBGoeVuu0bpGBtTCIk8rg9WNVevIgz2LI/edit?usp=sharing
    CONFLICT OF INTEREST: None Reported
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    Preserving Masks at Partners
    J. Jeffrey Semaan, Assist Prof | Harvard Medical School
    Partners healthcare system has now made masks mandatory for all healthcare providers.  
    My proposal for those working M-F (to be adjusted to healthcare workers work schedule):

    The SARS-CoV-2 virus disintegrates after a finite period of time (1-3). It seems that under most circumstances it disintegrates after 72 hours, but one study has some surfaces able to keep it viable up to 120 hours (3). If this is true, then the following should be safe (barring other unforeseen risks with method):

    Each healthcare worker receives 5 masks, each labeled with the person's initials and each designated M, T,
    W, Th, F.
    Each healthcare worker receives 5 PAPER bags.
    Monday--use M mask--at end of day put in M bag
    Tuesday--use T mask--at end of day put in T bag
    Weds--use W mask--at end of day put in W bag
    Thurs--use Th mask--at end of day put in Th bag
    Fri--use F mask--at end of day put in F bag
    --let all bags sit over the weekend
    (if irregular days worked: healthcare worker to receive 7 masks and 7 bags)
    This method would assure at least 140 hours of "isolation" of the masks and would be theoretically sterile of the SARS-CoV-19 virus.

    REFERENCES

    https://www.nejm.org/doi/full/10.1056/NEJMc2004973

    https://www.nih.gov/news-events/news-releases/new-coronavirus-stable-hours-surfaces

    https://www.journalofhospitalinfection.com/article/S0195-6701(20)30046-3/fulltext
    CONFLICT OF INTEREST: None Reported
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    Potential use of GoreTex for making PPE
    Abigail Zavod, MD, MPH | Clinical Development and Research
    Could GoreTex fabric be used to make masks and other PPE (such as gowns and drapes)? It is waterproof and breathable, and has pores that are 0.2 microns (1). COVID-19 is 1 micron in diameter. There is a growing home-based movement in the US to help make masks using cotton fabric, yet it seems that GoreTex might offer better protection. I know that I have at least two GoreTex shells that could be repurposed to create masks for HCPs. Is there a way that we can try to get traction for this idea? I have already reached out to the Massachusetts DPH. Please comment and share.

    REFERENCE

    1. http://cameo.mfa.org/wiki/GORE-TEX
    CONFLICT OF INTEREST: None Reported
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    Instapot PPE: Heat Sterilization in Consumer Electronic Multicookers
    Ryan Culpepper, Juris Doctor |
    Omnipresent electronic multicookers like the Instant Pot are designed for unattended use by laypersons. They include several modes that provide an option to apply moist or dry heat, above and below the boiling point, for a user-specified time. Even the high pressure setting on an Instant Pot would produce a temperature below the melting point of polypropylene, cellulose, and polyurethane, typical components of N95 respirators.

    Some studies examine the effect of heat sterilization on N95 respirators and appear to reflect little loss of filter capacity. It may be worth examining the effect on the narrower filter effectiveness of particles
    as large as the COVID-19 virus.
    CONFLICT OF INTEREST: None Reported
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    Heat it to Beat it: Infrared radiation-based simple approach for SARS-CoV-2 inactivation and decontamination
    Gyanu Lamichhane, PhD | Division of Infectious Diseases, Johns Hopkins University School of Medicine
    SARS-CoV-2, the causative agent of the current pandemic, is a coronavirus (1). Prior studies of related coronaviruses have revealed that they are vulnerable to higher temperatures. Casanova et al tested viability of coronaviruses TGEV and MHV in a matrix that mimicked respiratory secretions at various temperatures. They demonstrated that viral titers begin to decline most rapidly at 40oC and could not be detected after 6 hrs (2). Duan et al reported that SARS coronavirus CoV-p9 could be rendered non-infectious following exposure at 56oC for 1.5 hrs or by exposure to 90 W/cm2 UV irradiation for 1 hr (3). Using SARS coronavirus, Chan et al demonstrated a 2 log10 reduction in viral titer when exposed to 38o C for 7 hrs (4).
    As these studies used related coronaviruses, it may be reasonable to leverage the findings to test the hypothesis that decontamination of SARS-CoV-2 from personal protective equipment (PPE) and instruments can be achieved at temperatures that ensure their reusability. This hypothesis can be tested in a controlled laboratory setting and in hospital units that treat SARS-CoV-2 patients. This could involve exposure at a range of temperatures >40 oC using an infrared (IR) radiation source (eg, heater) for a defined duration, with subsequent screening of surfaces and equipment for active SARS-CoV-2 as an end-point. Whether UV irradiation additionally synergizes with IR should also be studied. If these measures clearly demonstrate that decontamination of surfaces and equipment can be achieved using IR radiation, then their implementation may have a measurable effect in addressing the current pandemic.

    Literature describing the exact molecular mechanism underlying heat inactivation of coronaviruses is lacking, but one may speculate that essential component biomolecules of these viruses such as nucleic acids, proteins and glycoproteins are irreversibly denatured, the resulting endpoint being the same as denaturation of biomolecules or membranes by detergent or alcohol-based agents currently in use. Now that we know the full genome map of SARS-CoV-21 and that it uses spike glycoprotein to enter human cells5, we can determine the irreversible denaturation temperatures of essential proteins such as the spike glycoprotein.
    In summary, findings from related coronaviruses likely have immediate utility in the current pandemic by providing insight to decontaminate PPE and surfaces especially in a resource limited setting where PPE are scarce but heat sources are available. If further studies specific to SARS-CoV-2 reveal that the minimum temperature and IR radiation dose required to inactivate SARS-CoV-2 is within the tolerable dose for humans, this simple measure may be implemented in rooms where infectious patients are under care to protect health care providers. Similarly, entrances, exits and holding areas in hospitals, schools, stores and mass transit could become points of surface decontamination as people enter and exit the facilities and may bring about measurable reduction in spread of SARS-CoV-2 and other heat labile pathogens. Given the magnitude of its potential impact and feasibility of rapid implementation, I propose that we critically test this approach. It has become abundantly clear that demand for PPE and disinfectants can overwhelm the supply chain even in resource plenty settings. One thing everyone has is heat. Can we ‘heat it to beat it’?

    REFERENCE

    (1) Zhou P, et al. Nature 2020
    (2) Casanova L, et al. Appl Env Micro 2010
    (3) Duan SM, et al. Biomed Environ Sci 2003
    (4) Chan KH, et al. Adv Virol 2011
    (5) Walls AC, et al. Cell 2020.
    CONFLICT OF INTEREST: None Reported
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    Barrier and Circulation Engineering
    Nader Ts, Doctor of Osteopathic Med | Arobridge Medical International Consulting, LLC, MD,NJ ; CUSOM, NC, USA, New Giza Univ SOM, Egypt
    Minimize physical exposure by building plastic/plexiglass or plastic rolls to divide rooms, while having mono flow of air/ventilation towards an exhaust behind patient, exhausted air can be heated (to a level that kills virus- not sure of actual temperature but some mentioned above 30 degrees Celsius or others mentioned above 56 ) or sterilized UV or other method.

    Tents/tunnels (similar to those made by toymakers for children but bigger) made of the plastic rolls can be quickly made in an already existing hospital or clinic space to isolate suspect patients before they enter. A well-ventilated tent or space can
    be used for triage (questions and temp check) or through a camera and mic in an isolated room. If they are suspect then they proceed through the dedicated room for exam through self- administered testing and or physical exam by doctor. All history should be taken while a full barrier stands between patient and doctor or nurse. and part of the physical exam requiring inspection and vitals can be done, select aspects of the physical exam that are necessary can be the last step done.

    The doctor can be wearing a long face shield made of the thin plastic (professionally made or homemade from thin plastic (like recycled big plastic bottles cut to size) or used in other industries that helps cover the mask so it doesn't have direct exposure of droplets or using a diving mask as was mentioned by others. The plastic rooms/tunnels can be either sprayed down by disinfectants that won't ruin it (not sure if diluted chlorine would be ok) or hot blowers that go above the killing temperature of the virus.
    CONFLICT OF INTEREST: None Reported
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    Masc with acetate folders
    Eduardo Quinteros, MD | Clinica Mayo Bell Ville, Argentina
    The sophisticated facial masks that we see on the media are out of the realm of possibility for most small clinics in my country. We obtain help from people that with 3D printers help us, but they can cost too much, so we follow a video from the internet and use folders with an acetate page, and with just a few cents we can have facial protection.
    CONFLICT OF INTEREST: None Reported
    Easily Manufactured Faceshields
    Caterina Delcea, MD | Colentina University Hospital, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
    Protective visors can be made from PETG, EVA foam, and Velcro to supplement the protection offered by surgical/home-made masks. A great example is this team of young Romanian engineers working together with medical students, volunteering to make visors (face shields) for doctors in need: https://viziere.ro/
    CONFLICT OF INTEREST: None Reported
    Reuse of N95
    Amanda Deskins, D.O. | Charleston Area Medical Center, Teays Valley Division
    I contacted Dr. Peter Tsai (retired from University of Tennessee), the inventor of the filtration fabric in the N95. N95 masks are made of polypropylene material, and are designed to tightly fit over your face with little leakage around the edge of the mask. I asked Dr. Tsai about reusing the N95 respirator, and what materials could be added in homemade masks to make them more effective. He responded with the following:

    MASK REUSE METHOD #1

    When reusing N95 masks, leave a used respirator in dry, atmosphere air for 3-4 days to dry it out. Polypropylene in N95
    masks is hydrophobic, and contains zero moisture. COVID-19 needs a host to survive--it can survive on a metal surface for up to 48 hours, on plastic for 72 hours, and on cardboard for 24 hours. When the respirator is dry in 3-4 days, the virus will not have survived.

    Take four N95 masks, and number them (#1-4).
    On day 1, use mask #1, then let it dry it out for 3-4 days.
    On day 2, use mask #2, then let it dry out for 3-4 days.
    Same for day 3, and day 4…

    MASK REUSE METHOD #2

    You can also sterilize the N95 mask by hanging it in the oven (without contacting metal) at 70C (158F) for 30 minutes—it is reported that COVID-19 cannot survive at 65C (149F) for 30 minutes.

    Use a wood clip to hang the respirator in the kitchen oven to do the sterilization.

    When sterilizing N95 masks, be wary of using UV light--keep N95 masks away from UV light / sunlight. N95 masks are degraded by UV light because it damages the electrostatic charges in the polypropylene material. It is unclear how long the masks can be exposed to UV light before they are ineffective.

    TIPS FOR REUSE METHOD #1 AND METHOD #2

    DO NOT place the respirator on a metal surface, or too close to metal--the temperature on the metal surface is higher than the air temperature.

    Keep N95 masks away from UV light / sunlight.

    When removing the mask, hold the edge of the straps attached to take off the N95 mask. Your hands may be contaminated at this time--don’t touch the inside part of the respirator. Wash your hands with soap for 20 seconds afterward.

    HOMEMADE MASKS

    It is not a good idea to use cotton masks when taking care of infected patients. The effectiveness of a material made of cotton is not high—it’s fiber is not fine enough, and it cannot be charged. An N95 mask is so thin because it uses Polypropylene which is made of millions of microfibers layered on top of each other that have been permanently electrostatically charged. An electrical field ionizes the air, and forces the ions deep into the microfibers which allows the polypropylene to act as a filter.

    However, using a HEPA filter with a face mask might increase its effectiveness, but it may make it harder to breathe. If you place another media over a face mask, the resistance to breathing increases—it is the sum of the two together. When adding an extra layer, make sure it perfectly covers the whole mask. Keep in mind it may make it more difficult to breathe.
    CONFLICT OF INTEREST: None Reported
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    Use of Ozone Medical Devices for PPE Decontamination
    Bernardino Clavo, MD, PhyD | Dr. Negrín University Hospital, Las Palmas, Spain
    Ozone is being used successfully for sterilization of water and air (in rooms and air installations) obtaining low ozone concentrations in large volumes during moderate/long time (1-5). Class IIb medical ozone generators are designed to obtain controlled moderated/high ozone concentrations in small/moderated volumes during short/moderate time. These are small and portable devices currently used in many private and some governmental centers around the world for several clinical conditions. Indeed, currently, the potential benefit of ozone as a complementary treatment in the management of patients with COVID-19 is under evaluation in 3 randomized clinical trials in China (6).

    However,
    with a different focus, class IIb medical ozone devices could easily lead to high ozone concentrations (50 to 80 µg/mL of O3/O2) in moisturized latex-free bags containing personal protective equipment (PPE), glasses and N95 masks, with the inactivation of COVID-19. Small and irregular spaces could be reached by O3/O2 because of gas diffusion properties. High ozone concentrations in humid environments could require a few minutes for COVID-19 inactivation, which would depend on ozone concentration. Anyway, it should be necessary to evaluate the most fruitful time/concentration relationship for virus inactivation and verify that the properties of protective equipment are not altered. This easy procedure could be performed in each center and facilitate the fast re-utilization of the protective equipment. Ozone is a very strong oxidant and there are preliminary projects who assay the possibility to create sterilization devices with ozone.

    Additionally, a considerable time (no risk-free) is required for an appropriate PPE dressing/undressing procedure. So, it could be interesting to evaluate the possibility to sterilize the PPE without undressing, decreasing the risk for the health workforce. Thus, for example, it could be placed a closed standard oxygen mask during the requiring time (probably lower than 10 minutes), while the standing staff with its PPE could be inside a big and closed plastic bag (below the neck) to sterilize the PPE in situ. Later, staff could assist other patients or go to other lower-risk areas.

    REFERENCES
    1. Thill SA, Spaltenstein M. Toward efficient low-temperature ozone gas sterilization of medical devices. Ozone Science Engineering. 2019; DOI: 10.1080/01919512.2019.1704217.
    2. Jamil A, Farooq S, Hashmi I. Ozone disinfection efficiency for indicator microorganisms at different pH values and temperatures. Ozone Science Engineering. 2017;39(6);407-416.
    3. Schneider W, Rump HH. Experiments for waste water treatment with ozone in
    combination with adsorption procedures. Ozone Science Engineering. 2008;4(1):3-14.
    4. Murray BK, Ohmine S, Tomer DP, et al. Virion disruption by ozone-mediated reactive oxygen species. J Virol Methods. 2008;153(1):74-77.
    5. https://www.ozonesolutions.com/knowledge-center/ozone-effects-on-pathogens.html
    6. ChiCTR2000030165, ChiCTR2000030102 and ChiCTR2000030006, accessible the 23rd of March 2020 at http://www.chictr.org.cn/enindex.aspx

    Bernardino Clavo, MD, PhyD, Dr. Negrín University Hospital, Las Palmas (Canary Islands), Spain and International Scientific Committee of Ozone Therapy
    Gregorio Martínez-Sánchez, Pharm. D, PhyD., International Scientific Committee of Ozone Therapy
    Adriana Schwartz, MD, PhyD, International Scientific Committee of Ozone Therapy
    Pedro Serrano-Aguilar, MD, PhyD, Servicio de Evaluación del Servicio Canario de Salud (SESCS), Tenerife (Canary Islands), Spain
    CONFLICT OF INTEREST: Grants related with ozone treatment from: the Instituto de Salud Carlos III: PI 17/00120 (NCT03282695) and PI 19/00458 (NCT04299893), from FIISC: PIFUN44/17, from Colegio Oficial de Médicos de Las Palmas: I19/18 and I24/15), and from Fundación DISA: 016/2019. Ozone medical generators used at our Hospital have been partially supported by Dr. Hansler GmbH, Iffezheim, Germany.
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    Emergency PAPR from alternative supply chains
    Mads Olesen, Bsc. Computer Science | Aarhus University
    I've put together a preliminary PAPR design to use completely different supply chains from other masks in order to scale up production rapidly. Instructions are https://tinyurl.com/wvs7rwy
    CONFLICT OF INTEREST: None Reported
    Use of GoreTex for PPE
    Abigail Zavod, MD/MPH | Pharma
    GoreTex is a breathable, washable material with pore sizes of 0.2 microns (1). COVID-19 is 1 micron. Could GoreTex be used for masks and other forms of PPE such as drapes and gowns? There are many homebound people in the US who are making masks out of cotton to try to help with shortages, but if recycled GoreTex clothing was used, it might be more effective at preventing transmission of the virus. I am trying to get traction for this idea and am not sure who to contact.

    REFERENCE

    1. http://cameo.mfa.org/wiki/GORE-TEX#Description
    CONFLICT OF INTEREST: None Reported
    Using DOD gas masks as stop gap PPE
    Hernando Ortega, MD, MPH; ABPM Chair | Contract physician, US Air Force
    The modification and use of DoD gas masks (particularly the MCU 2P and M40 chemical masks) – in bulk – could be a stop gap solution for the shortage of coronavirus PPE by healthcare professionals in the U.S.

    The MCU2P mask has a couple of benefits. The entire system (except cartridge) can be “dunked” or hand washed for cleaning. The mask has been proven to be both durable and reusable. The inhalation pathway is through the cartridge, but the exhalation pathway is not, thus preserving the cartridge from moisture, fomites, and other degrading environmental
    elements. These masks are easily sized. These masks face shield can be removed for extra cleaning while still in primary mask.

    It would require a crash development of a new viral filtering (N-95 like) cartridge for the MCU2Pand M40 mask. Modifications would involve developing a new tiny cartridge for the MCU 2P or M40 cartridge port that would be reusable, could be easily sanitized (or even disposable), and made as simply as the mask is to pull apart and clean.

    By making military gas masks easily cleaned and reusable, this short term “fix” can help bridge the gap needed for more robust methods and technologies to become available to our first responders.
    CONFLICT OF INTEREST: None Reported
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    Alternative Personal Particulate Filtration During N95 shortage
    Joseph Shirk, MD | David Geffen School of Medicine at UCLA
    The quantity and quality of suggestions here are an exemplar of the innovative spirit that will allow us to effectively address this crisis. Many of the proposed alternatives to respirator-grade filtration use non-disposable hardware which can then be sterilized, such as scuba masks and anesthesia facemasks. Coupled with disposable filters, this technique could prove to be an practical stopgap until the N95 shortage is alleviated by increased production and distribution. However, the filters needed to make this solution effective are either made through a similar manufacturing process as the N95, or are essential to other aspects of COVID-19 patient care, such as ventilator circuits.

    N95 masks are designed to filter the most penetrating particle size of 0.3 μm at an efficiency of 95%, and paradoxically filter smaller particles with greater efficiency due to electrostatic capture. The coronavirus nominally has a particle size of 0.13 microns, and thus is effectively filtered by the N95.

    The Minimum Efficiency Reporting Value (MERV) rating is used for household and industrial air filtration systems. The MERV 16 rating certifies the filtration of 0.3 μm particles at an efficiency of 95%, much like the N95 mask. I propose that pleated MERV 16 air filters such as those used in industrial heating and air conditioner units may be re-purposed and used in conjunction with the above non-disposable hardware (scuba masks or anesthesia masks) to create a respirator that does not use other essential filters. The MERV 16 filters may be cut into flat disks that can be affixed over the air intake of these masks and used disposably, while the mask itself may be sterilized and reused. I believe this combination accomplishes the trifecta of using readily available materials, avoiding depletion of other vital medical equipment, and most importantly, maintaining optimum protection for healthcare providers.
    CONFLICT OF INTEREST: None Reported
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    Microwaving PPE
    Gustavo Caetano-Anolles, PhD | University of Illinois at Urbana Champaign
    Microwaves have been used effectively in microbiology to sterilize different types of equipment. For example, microwave sterilization of plastic tissue culture vessels destroys in 3 minutes viruses such as polio type 1, parainfluenza type 1 and bacteriophage T4 (Sanborn et al., Applied Environ Microbiol 44(4): 960-964, 1982). The CDC Guideline for Disinfection and Sterilization in Healthcare Facilities (Rutala et al. 2008) states that "The microwaves produced by a "home-type" microwave oven (2.45 GHz) completely inactivate bacterial cultures, mycobacteria, viruses, and G. stearothermophilus spores within 60 seconds to 5 minutes depending on the challenge organism (Latimer et al. J Clin Microbiol 6:340-342, 1977)".

    I propose removing metal clips from N95 masks, placing them in standard microwave ovens with a beaker containing 100 ml of water, and microwaving the personal protective equipment (PPE) for at least 3 minutes.

    I used microwaves in the microbiology laboratory for at least 10 years to sterilize a number of laboratory items very effectively. During that time I routinely monitored bacterial contamination. The same technique should destroy SARS-CoV-2, since the dielectric nature of the virus makes it sensitive to electromagnetic energy. Note that microwaved masks remain dry after sterilization (the water in the beaker acts as buffer), and the metal clip could be assembled back. The procedure can be repeated a number of times with a same mask for multiple instances of reuse.
    CONFLICT OF INTEREST: None Reported
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    Vacuum Cleaner bags
    Caterina Delcea, MD | Colentina University Hospital, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
    Anna Davies et al proved in 2013 that the vacuum cleaner bag was closest to the surgical mask in terms of prevention of droplet and particle dissemination when coughing (1, 2).

    REFERENCES

    1. https://www.cambridge.org/core/journals/disaster-medicine-and-public-health-preparedness/article/testing-the-efficacy-of-homemade-masks-would-they-protect-in-an-influenza-pandemic/0921A05A69A9419C862FA2F35F819D55

    2. https://nypost.com/2020/03/20/doctors-are-now-running-out-of-face-masks-heres-how-to-make-your-own/
    CONFLICT OF INTEREST: None Reported
    Omnidirectional Ultraviolet (UVC) Chamber Irradiation for Crisis Decontamination and Reuse of Select Personal Protective Equipment (part A)
    Terry Donat, MD FACS FICS | Otolaryngology-Head and Neck Surgery, FHN Memorial Hospital, Freeport, Illinois
    Single-use, high performance PPE for the care of infectious disease patients is typically discarded after gross material soiling, biological or chemical contamination, loss of performance, loss of integrity, progression between patients and both ending shifts or frequent brief specific periods of work. In the current international COVID19 healthcare crises, the available supplies of PPE are under extended strain and very prone to exhaustion if discarded for conventional causes without creative, effective conservation efforts.

    Reuse of contaminated PPE, substandard PPE or no PPE is incompatible with maintaining healthy and effective responder workforces --- whether dealing with COVID19, other human
    pathogens, normal body flora or environmental biological agents. As PPE resources become scarce for protection of both patients and providers, urgent deployable methods for adaptable sterilization and extended reuse of PPE become, not only relevant, but critical and existential. It remains preferential to both extend use and reuse sterilized PPE, such as N95 masks designed for COVID19 viral protection, even if degraded, over accepting any amount of new inferior filtration masks never designed to protect against the exceptional viral load shedding observed in this disease.

    Ultraviolet Germicidal Irradiation (UVGI) using commercial UVC light (254nm; 55 watts source) robotics has been keenly proposed and safely used for the effective decontamination and reuse of single-use N95 masks within conventional healthcare settings and subject to conventional healthcare facility room designs. Alternatively, immediate deployment of enhanced UVGI capabilities for mobile, fixed or field facilities may be easily accomplished by adaptively constructing chosen spaces into UVC reflecting chambers ---- using widely-available off the shelf components ---- for continuous UVC disinfection of select PPE and devices.

    Adaptive Solution
    Reflective aluminum foil and aluminum-metallized surfaces are the most highly reflective metallic surfaces known for Germicidal UVC light (254nm). If walls, floor and ceiling surfaces of a fixed room or any other space were completely lined with highly-reflective aluminum-based materials to form a UVC-reflecting chamber, the ongoing capability of UVC disinfection using commercially available UVC light sources within such chambers is widely and rapidly deployable. This configuration maximizes both the incident UVC light and reflected UVC light without room surface attenuation from all possible angles (omnidirectional irradiation eliminating significant shadowing) onto the target articles with a total estimated chamber UVC light intensity at least double the intensities of each of the sources.

    Example (for comparative cost estimates)
    A 10’ x 10’ x 10’ tent, room or section of hospital corridor may be transformed by stapling reflective lining and placing UVC sources using the following commercially available materials. Estimated construction time with materials on site is 2-3 hours.

    (1) 4 (four) Germicidal Lamps to be positioned one at each corner. Bulb Options: UVC light bulb (254nm; 60 Watt LED; $80.00 USD) with E26 standard bulb base OR 38 Watts UVGI disinfection lights with control timer (254nm; 38 Watts; $100 USD): COST TOTAL: 400.00 USD

    (2) 600 sq. feet of Reflectix (80% UVC reflective; $0.70 USD per sq. ft) from Lowes, Menards and some Home Depots home supply stores. COST TOTAL: 420.00 USD

    Suggested Applications:
    (1) To extend use and reuse select PPE 
    (2) To decontaminate worn PPE on high-exposure healthcare providers prior to doffing (handheld ad hoc eye shielding) 
    (3) To decontaminate worn PPE on high-exposure healthcare providers at 60-90 minute intervals to decrease cumulative PPE surface viral loads during shifts or after high-exposure procedures.

    David Smith, CEO – ALLCOOL USA, McClean, Virginia
    Bruce Bina, CEO – Blue Ocean Research and Development Corporation, Naperville, Illinois
    Leah Roberts, Consultant – Blue Ocean Research and Development Corporation
    Brad Pioveson, Consultant – Blue Ocean Research and Development Corporation
    Shawn Shianna MD – Otolaryngology, FHN Memorial Hospital, Freeport, IL
    CONFLICT OF INTEREST: None Reported
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    Rubber Factory Autoclaves
    Steven Rodgers, Associates | EmergenTek LLC
    Recycling and reuse of PPE might help extend scarce supplies of these items in times of extreme scarcity. The key to recycling and reuse of PPE is sanitizing/disinfecting eligible products such as masks, gowns, etc. Medical disinfecting is being applied to new stock to supply the medical industry.

    There is an industrial source for steam autoclaves that might be employed to sanitize large quantities of used PPE. Many Rubber manufacturers have autoclaves for vulcanizing rubber that go far in excess of the required 171°C and have hundreds of cubic meters of capacity. Many are as large as
    3 meters in diameter and 12-20 meters long. These are positioned around the United states. I am certain that Rubber manufacturers would volunteer their equipment to help deter the spread of this infectious disease.

    Feel free to contact me for more information.
    CONFLICT OF INTEREST: None Reported
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    Rationalising PPE in the ICU
    Filipe Sousa Cardoso, MD MSc | Curry Cabral Hospital
    Our PPE in the ICU consists of 2 sets: (a) for aerosol-generating procedures, a full-body protective suit, FFP2 mask, goggles, visor, 2 pairs of gloves, gown, leggings, and hospital shoes; (b) for regular bedside care, a cap, FFP2 mask, goggles, visor, 2 pairs of gloves, gown, and hospital shoes' covers.

    To optimize the availability of PPE, we have taken the following measures:
    (a) goggles, visors, and hospital shoes are being reutilized following standard decontamination with sodium hypochloride;
    (b) the minimum of professionals needed, including at least one senior doctor and one nurse, enter each room
    or zone together in a prespecified time, after deciding all interventions to be made (e.g. collecting samples, proning patients, or inserting lines);
    (c) regular medications and materials used at the bedside are available in reasonable quantities inside each room or zone;
    (d) blood gas and ultrasound machines are also inside the COVID area;
    (e) request of chest-x rays has been minimized to clinically essential;
    (f) all contact with patients is minimized to the essential bedside care, with visitors not allowed to go in;
    (g) professionals are required to have a shower with soap at the end of each entrance to any room or zone; (h) professionals use surgical mask outside the COVID area.

    Filipe Sousa Cardoso, Tânia Sequeira, Ana Martins, Cristina Manso, Nuno Germano
    CONFLICT OF INTEREST: None Reported
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    Remote Control Time-lapse Exposure Device for X-rays
    Jun Liu |
    Chest radiography is widely used for the screening and diagnosis of COVID-19. Bo Jiang and Weijun Situ et al [1] designed a convenient remote control and time-lapse exposure device for X-ray.s It can be assembled in any of the existent X-ray machines at low cost and accommodate a large amount of chest radiography workload. Using the device can substantially minimize the radiation dose of medical staff and the time contacting patients, and further reduce the incidence of cross-infection between medical staff and patients. The device is protected by China's national utility model patent, and an application for an invention patent is under review.

    The device consists of an exposure control circuit, power button, time delay trigger button, radio frequency remote control, radio frequency receiving antenna and other modules. It has two remote exposure modes: remote control bypass obstacles and adjustable time delay trigger.

    About 320 chest radiographs were performed by Shang Jiang and Kun Yu with the help of the device in the Mobile Cabin Hospital of Wuhan, Hubei Province, China. It not only protected our medical staff from radiation but also improved work efficiency because staff no longer needed to wear a lead apron. None of our equipment was contaminated with SARS-CoV-2.

    The number of patients with confirmed COVID-19 is rapidly increasing all around the word. Protecting medical staff from getting infected by SARS-Cov-2 is very important to fight the outbreak. We hope the experience can help technologists to better protect them and improve their work efficiency.

    [1] The Second Xiangya Hospital, Central South University. A mobile exposure controller for X-ray and mobile X-ray machine [P].China Patent:201621011706.9,2017-03-29.
    CONFLICT OF INTEREST: None Reported
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    Disinfection/Decontamination Protocols For PPE
    Antoine Marmignon, MD |
    Publications reviewing decontamination of PPE :

    https://doi.org/10.1097/PTS.0000000000000600
    https://doi.org/10.1080/15459624.2015.1018518
    https://doi.org/10.1093/annhyg/mer054
    https://doi.org/10.1016/j.ajic.2010.12.021
    https://doi.org/10.1080/15459624.2011.585927
    https://doi.org/10.1080/15459624.2010.484794
    https://doi.org/10.1016/j.ajic.2010.07.004
    https://doi.org/10.1016/j.ajic.2018.02.018
    https://doi.org/10.1371/journal.pone.0018585

    Publications reviewing decontimanation of homemade PPE :

    https://doi.org/10.1017/dmp.2013.43
    https://doi.org/10.1371/journal.pone.0002618
    CONFLICT OF INTEREST: None Reported
    PPE Medical Gown - Free Sewing Pattern and Instructions for Distribution
    Jan Roach, AA Family Relations | Arizona
    I created free printable PPE Medical Gown pattern instructions available at

    https://onedrive.live.com/?authkey=%21AOIPumaxG1cl0O8&cid=5A0926368BA2E777&id=5A0926368BA2E777%2117238&parId=5A0926368BA2E777%21136&o=OneUp,

    which I adapted from a free video pattern by Cari Brinkerhoff Williams  at

    https://www.youtube.com/watch?v=O0goN9DgNxg&feature=share&fbclid=IwAR0OzlM4zSt5zB1bfRnuL88g7KK-oL-Td7OiVCCSxPlnTFMDC-cx-z8Ri3I
    CONFLICT OF INTEREST: None Reported
    Reusable Elastomeric Masks
    Santosh Bhaskarabhatla, MD | Rutgers - Robert Wood Johnson Medical School
    The long term PPE solution will need to be something reusable. Commendably, 3M has increased its monthly output to 100 million masks, which equates to 1.2 billion masks over the next year. [1]

    Will this be enough? The estimated need for masks may exceed 3 billion over the next year, as per the Department of Health and Human Services. [2]

    Elastomeric Respirators, as other comments have noted including Dr. Stella Hines’ excellent comment, offer potentially better protection than disposable N95 masks, and they are reusable. They can easily be washed and bleached once the cartridges are removed
    [3].

    Many elastomeric respirators are probably sitting unused in stores, offices, homes, as they are commonly used in other industries. Let’s get a drive to donate these reusable masks and to get everyone fit-tested for them.

    If donations are not possible, can we do buybacks of these Reusable elastomeric masks?



    References:
    [1] Roman, Mike. 3M CEO post on COVID 19 response. Https://News.3m.com March 22, 2020.
    [2] Kadlec, R, quoted in “HHS clarifies US has 1% of face masks needed for ‘Full blown’ Coronavirus pandemic.” Http://www.cnbc.com/ March 4, 2020.
    [3] Bach, Michael. NIOSH Science Blog. Https://blog.cdc.gov/. July 6, 2017.
    CONFLICT OF INTEREST: None Reported
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    Household Water-activated Surfactants as Antivirals
    Timu L, Ph.D. | Town of Wellesley, MA
    Has anyone looked into using household liquid dish detergent to get an improvement in the efficacy of the homemade cloth surgical masks being made for hospitals and also being used by the general population?

    Hypothesis

    If a cloth mask was washed, rinsed, and then dipped in a dish pan containing a fresh mix of dish soap and water and let dry, the detergent remaining in the fabric would deactivate viruses when moistened by the breath.

    Data points

    1) Kleenex makes US Federally approved* (Environmental Protection Agency) "anti viral" tissue whose active ingredients are citric acid 7.51%,
    sodium lauryl sulfate 2.02%. The instructions say "a moisture activated middle layer that kills 99.9% of cold and flu viruses (Rhino TYpe 1A and 2, Influenza A and B, RSV) in the tissue within 15 minutes"

    https://www.cvs.com/shop/kleenex-anti-viral-facial-tissues-cube-box-68-ct-prodid-1340050

    2) Surfactants like sodium lauryl sulfate in acidic solutions in the presence of water deactivate viruses similar to COVID-19.*

    3) Liquid dish soap + water deactivates these kinds of viruses in 20 s (1)

    4) E.g. US brand 7th Generation free and clear dish soap contains sodium lauryl sulfate and citric acid.

    *EPA registration #9401-10

    REFERENCE

    1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2813869/
    CONFLICT OF INTEREST: None Reported
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    Use Half-Face Elastomeric Respirators and reuse P100 cartridges through EtO sterilization
    Joel Malak, RN, BSN, MPH, COHN-S |
    There are a couple of advantages to switching to Half-Face Elastomeric Respirators with P100 cartridges from disposable N95s. The Half-Face respirators can be sterilized and repeatedly used, are less costly than the disposables, and are far more comfortable when worn for extended periods of time. Previous comments have also indicated that EtO sterilization may be available in most of the facilities serving COVID patients.

    Prescriptively, the 3M 7500 Series with the 3M 7093 P100 filter cartridge would be my preferred respiratory protection if I were currently working in this environment. The 7093 cartridges can be removed from
    the respirator facepiece daily, appropriately packaged and sent for local EtO sterilization. The 7500 respirators would also require daily cleaning but they have a hard plastic case that can be cleaned with a 5000 PPM bleach solution.

    The question is does the EtO sterilization process in any way negatively impact the filtration properties of the "glass/fiber/paper" filter materials in the 7093 cartridges.

    Alternatively, there are also other appropriate cartridges (3M 2097 or 3M 2071) that use polypropylene filter materials if that material may be more safely EtO-sterilized.





    https://www.3m.com/3M/en_US/company-us/all-3m-products/~/3M-Particulate-Filter-7093-P100-60-EA-Case/?N=5002385+3294776429&rt=rud

    https://www.3m.com/3M/en_US/company-us/all-3m-products/~/3M-Professional-Paint-Respirator-7500-Series/?N=5002385+3294427657&preselect=3293786499&rt=rud

    https://www.3m.com/3M/en_US/company-us/all-3m-products/~/3M-Particulate-Filter-7093-P100-60-EA-Case/?N=5002385+3294776429&preselect=3293786499&rt=rud
    CONFLICT OF INTEREST: None Reported
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    Support of PPE equipment
    Brendan Lake, B.Industrial Des (Hons) | Production-partners.com
    A fellow Doctor and good friend of mine put me onto this group. I have been running a design and contract manufacturing company in China for over 10 years and have lived over there myself for 7. I am now based in Los Angeles but the rest of my team are China and HK. Our business has been designing, manufacturing, sourcing, QC, and shipping of millions of products for medical, sporting, consumer products for leading brands such as Pelican, Mophie, Uber, Revlon, etc.. but due to the Covid-19 crisis we have been approached by many parties for assistance sourcing products that are in shortage.

    We currently have production capability for KN95 (the China equivalent of the N95) mask as well as surgical masks (both of which are CE- and FDA-approved) and and are in the process of sourcing face shields, protective clothing, nitrile gloves, etc.. and will add them to our offering once we have performed our due diligence to ensure product certifications, factory certifications, pricing are in order.

    We are currently in contact with a number of global medical supply companies, the Australian government, and the UK NHS, who have provided us lists of additional equipment that they need which we are now also sourcing.
      
    We are open to taking orders, but we do have MOQ requirements on the masks starting at 100K units.

    I also understand that there has been substantial price-gouging and many scams for counterfeit masks which we 100% are not. Our company's reputation is paramount to our business and will continue to act ethically and ensure we supply good quality products to our clients. The pricing we have for the FDA and CE approved KN95 masks is : 100K@US$1.61, 250K@US$1.57, 500K@US$1.52, 1mil@US$1.40, 2.5mil@$1.37

    As you can see this pricing is far below some of the crazy numbers that are out there are the moment.
    Please note that this pricing is ex-factory (china) so we would also have the air-freight cost to send them over which we would be 100% transparent on showing all shipping docs and would be a pass on cost to the purchaser. For the comparison chart between KN95 and N95 masks please refer to this 3M chart: https://multimedia.3m.com/mws/media/1791500O/comparison-ffp2-kn95-n95-filtering-facepiece-respirator-classes-tb.pdf

    We can be reached at medical@production-partners.com

    Please no spam and 100K is the minimum order qty as this is dictated by our factory.

    I hope we can be of assistance to you and we will add in additional products once we have them.

    Regards
    Brendan
    CONFLICT OF INTEREST: None Reported
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    Reusable covers for N95 masks
    Kristin Morrison, M.D. | Hotel Dieu, Kingston Ontario Canada
    I am a pediatrician, medical educator, costume designer and seamstress. My husband is family doc working in a small rural hospital which is low on the list for supplies - given the greater need of the larger centres so we, like others are looking for any options. I have developed a reusable fabric cover that fits over the N95 masks which are easy to put on/take off, minimally increase work of breathing through the mask and can be easily manufactured en mass by the average home sewer. Prolonged use of N95s has 2 problems - masks become contaminated and risk transmitting infection, and the filters become clogged - making them more effective for filtering, but decreasing airflow and increasing work of breathing. By using a cover over the masks, we are hoping to address both of these issues and prolong the usable lifespan of each N95.

    Covers are made with 2 layers of a medium/heavy weight t-shirt material which in ideal situations has been shown to block up to 50 % of virus sized or larger particles. Stretch from the material helps mold the cover to the mask, without interfering with the seal - so primary protection is from the N95. Elastic ear loops at the sides automatically gather the edges of the cover when it is put on. Covers can be washed and dried as per current guidelines for contaminated linens - although elastic will probably degrade but this design allows this to be easily replaced. Our limited testing has found these to be fairly easy to use and do not significantly increase the work of breathing. Effectiveness would decline as material wears out, so while we are considering using new t-shirts if needed, I would not recommend recycling old, thin or inexpensive ones.

    I have no ability to test the effectiveness of these covers - but have tried to use the best available data in creating these. If anyone is willing and able to review or do any testing on these, I would be grateful for any feedback. I am also working on a redesign of the fabric surgery mask to try address some of the deficiencies of many of the commercial and home sewn versions identified by the various trials. I will be posting patterns and background research to Facebook - once someone else has created the page.
    CONFLICT OF INTEREST: None Reported
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    Contact beauty salon for surgical mask and exam gloves
    Andy Guy | Salon professionnal
    We have collected more than 2000 surgical face masks for our local ER. Other nailtechs from my area also donnate surgical masks.

    Many salons stocked gloves and alcohol by the gallons before all of this started. Make a call on the News for those who wants to donate.

    Volunteers can all sew PPE gowns from plastic paint drop cloth. One can contact Lowes and home depot to buy rolls of plastic drop cloth.

    Face shields: modified contractor head lamps with clear vinyl report cover from office depot.
    CONFLICT OF INTEREST: None Reported
    NaCl filter for homemade masks
    Kristin Morrison, MD | Hotel Dieu Hospital, Kingston, Ont
    I know that the article about using NaCl coating on standard filters for surgical masks has already been referenced (1). And I understand that this technique has been further refined for commercial production with anticipated availability in 18 months. However, reviewing the methods sections suggests that the materials are commonly available - with the exception of the filter material, and the process could likely be adapted to any home or commercial kitchen. If this process is even half as effective using cotton or other readily available material, it should be possible to rapidly produce filters that could be inserted into a pocket of home sewn masks. As the materials are non-toxic, the masks can be laundered with the filter intact, and once decontaminated the filters can be sent back to be re-coated and then reused. This process looks simple enough for those countries lacking the resources to purchase or manufacture standard disposable surgical mask so even if this type of DIY process is only half as effective - it would provide significantly greater protection than what is currently available to many.

    I am wondering if anyone can reach out to the authors and ask if during this world wide critical shortage of masks and materials, they would consider assisting in developing this idea as a humanitarian gesture.

    REFERENCE

    1. https://www.nature.com/articles/srep39956
    CONFLICT OF INTEREST: None Reported
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    PPE and Art Conservation
    Sarah Reidell, MLIS and CAS Conservation | University of Pennsylvania Libraries
    How can those outside of medicine share our expertise and fabrication skills?

    Art conservators are the MacGyvers of the cultural heritage world and we are eager to contribute to this call for PPE.

    I am an art conservator at Penn and my profession extensively uses PPE to safeguard us as we work with solvents, create dusts, remediate mold, etc. My lab fabricates exhibit cradles and supports out of 0.20” or 0.40” PETG (sold as Vivak) that could easily be repurposed as face shields for 3D printed visors. We have large rolls of thick Mylar (PET). We
    also use textiles that can be thermally or ultrasonically welded — soft HDPE non-woven olefin fibre (sold as Tyvek) and non-woven, spunbound polyester (sold as Hollytex or Reemay) — into filtering or clinical applications. Some of us are looking at how we could assist with fabricating isolation boxes out of Plexiglas and aluminum screw posts.

    How can we connect with other fabricators and leverage this expertise to benefit front-line medical and responder staff?
    CONFLICT OF INTEREST: None Reported
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    Full face snorkel mask
    Evan Dabreo, MD | University of Virginia
    Adding to the comments from Anh L Tran, BSN, Derek Farley, D.O. and others regarding using a snorkel as PPE. I took my full-face snorkel mask and with the air intake occluded took a deep breath. The mask seals very well and tightens down on face without any air leakage. A HEPA MERV16 filter offers similar filtering capacity to an N95 mask. If the filter is removed from its carboard frame you can form a pocket around the top snorkel which has no appreciable resistance to breathing if appropriately sized. I’m not sure how much the pleats contribute efficiency of filtration but this seems like a very feasible idea.
    CONFLICT OF INTEREST: None Reported
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    Reuse of Masks and PPE by disinfection with Large Scale Ozone
    Steven Russek, PhD | Engineering Scientist
    Ozone has proven effective in disinfecting objects contaminated with COVID 19 - like viruses (SARS) - see other references.

    A small scale set of experiments should be performed using ozone concentrations representative of portable commercial-scale ozone generators to determine the efficacy of the virus destruction. Bench top small-scale ozone generators placed in virology labs where virologists/chemical engineers/mechanical engineers could collaborate to verify efficacy and, in parallel, plan for scale up. For example at MT Sinai hospital with engineers from Columbia or NYU or CCNY or a combined team.

    In parallel, new masks should be treated
    to determine the process conditions that assure the residual ozone levels are acceptable. There is a likely need to blow multiple chamber volumes of fresh air through the decontamination chamber. Pressures should be low enough to use PVC or other plastic for disinfection chambers

    While most suggestions suggest the use of small scale disinfection with Ozone - I suggest hospital that hospitals in NYC use a portable commercial-scale ozone generator connected to chambers that contain contaminated masks. Data from the small scale systems can be used to determine cycle time for disinfection.

    If needed - sealed zip lock bags could be used so that disinfected masks/garments could be treated individually but on a large scale - increasing throughput.

    A collaboration between Faculty of Chemical Engineering or a team from Industry (PRAXAIR or Air Products - Applied R&D), medical professionals/virology, and supplier of commercial-scale ozone generators would be well suited to getting this implemented. Such a team could address medical, engineering, safety and environmental aspects ....

    Good luck
    CONFLICT OF INTEREST: None Reported
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    Delivery and Surveillance by Drone
    WeiPin Chang, Associate Professor | School of Health Care Administration, Taipei Medical University, Taiwan, Republic of China
    As the number of patients with COVID-19 peak, demand for personal protective equipment (PPE) has also skyrocketed. The delivery of such indispensable accessories has never been more paramount. Here, we propose using drones to deliver PPEs to the most vulnerable (hospitals, long-term care center), thereby reducing human-human contact which would help to alleviate cluster infections. Moreover, drones can access the most remote areas for example by flying over extended bodies of water and mountains. The flying capacity of drones can also mobilised to disperse crowds. They could pinpoint the mass congregation of people from afar. The benefits here are actually two-fold as they also render the deployment of police officers redundant for this social distancing measure.  This would inevitably help to prioritize the allocation of PPEs to the most vulnerable, reducing the risk of cluster infections and thereby sparing them from inefficient use.
    CONFLICT OF INTEREST: None Reported
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    Use of Phase Change Material under PPE during warm season
    Rahul Narang, MBBS, MD, PhD | Professor, Microbiology, MG Institute of Medical Sciences, Sevagram, Dist Wardha, Maharashtra, India
    Since the temperature in warmer countries is soon going to soar, it would be highly uncomfortable for the health care staff to wear PPE for long hours. After discussion with our undergraduate think tank, we propose incorporation of phase change material (PCM) vests and pants under the the PPE that will make a comfortable environment for the wearer. Phase change material stores thermal energy as latent heat in its crystalline form. On changing phase this latent heat is released or absorbed, allowing the ambient temperature within the system to be maintained. This offers encapsulations to the extreme temperatures and is thin enough to give good overall heat transfer coefficient.

    Ref: Babu VR, Arunraj A. Thermo regulated clothing with phase change materials. J Textile Eng Fashion Technol. 2018;4(5):344-347. DOI: 10.15406/jteft.2018.04.00162
    CONFLICT OF INTEREST: None Reported
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    Potential Sterilization Options
    Komal Talati, MD |
    With the need to sterilize and reuse N95 masks especially in smaller hospital practices and community health centers who do not have the resources often needed to sterilize, we should look at readily available products.

    - Baby bottle steam sterilizer and dryers
    - Wabi UV sterilizer
    - Microwave breast pump sterilization bags
    CONFLICT OF INTEREST: None Reported
    Using NarrowBand UV-B Phototherapy Whole Body Phototherapy Lights in Combination with Ozone Sterilization in conserving PPE - Outpt. Setting
    Geoffrey Galgo, DABFM | Guam Medical Care, LLC and the Governor's Physician Advisory Committee for COVID-19
    Since early March 2020, when we had our first cases of COVID-19 on Guam, and the WHO declaring SARS-CoV-2 as a global pandemic, I had to use the power of innovation in the setting of serious necessity to protect my medical staff with limited PPE supplies from COVID-19. Originally our whole body narrow-band UV-B phototherapy lights were primarily used for treatment of my vitiligo and psoriasis patients, and when SARS-CoV-2 first emerged on Guam, I applied the proven science of UV radiation in the safe application to conserve our PPE for reuse provided that the protective gear had no contaminated bodily fluids to sterilize our protective gear. UV radiation has been known through proven studies to inactivate the SARS virus by destroying the RNA nucleic acid core.

    In addition, I also applied ozone sterilization techniques using an ozone generator to double-up on the sterilization process for conserving our PPE. O3 has been proven to be a potent oxidant to fragment the envelope integral membrane protein of SARS-CoV-1 virus and destroy the inner nucleic acid core rendering the virus inactivated during the outbreak in 2003 in Hong Kong. Extensive research has been done in the past with a proven safety record in the process of sterilization to inactivate the SARS virus. SARS-CoV-2 also within the same family of the beta coronaviruses have very similar characteristics to the SARS virus. So Ozone may prove to have the same potential to inactivate COVID-19.

    Within days, we were notified by Guam Department of Pubic Health and Social Services that community spread was occurring within the community so we treated everyone walking into our out-patient ambulatory care facility as if they already have COVID-19 so conserving our PPE was even more critical during this crisis.

    We also used these methods of sterilization in the process of decontaminating our makeshift isolation room and procedure rooms. After which, our staff would apply surface disinfectants to disinfect examine tables, counters, critical equipment to include door knobs and other structures that needed disinfecting. Last but not the least we used aerosol disinfectants to provided the safest methods to prevent cross contamination.

    During times of crisis with the resupplying of our personal protective equipment remaining uncertain, innovation will always play a role. Using proven and safe applied sciences in UV and Ozone technologies remains to be seen as a possible temporary solution in the conservation of PPE for reuse. Being a Board Member of the Governor's Physician Advisory Board, many physician colleagues from all specialties agreed to apply these sterilization methods after my powerpoint presentation on this topic of conservation of PPE during our meeting with Governor Lou Leon Guerrero. Our first responders will conserve their N-95 mask and face shields for reuse provided that the above aforementioned conditions are met. Additionally, the healthcare professional and workers at our COVID-19 designated hospital and step-down skilled nursing facility will use these methods until more PPE supplies become readily available.

    As of March 26, 2020 we have 45 COVID-19 cases and one COVID-19 related death in the US Territory of Guam having a population of 170,000 residents.


    Geoffrey P. Galgo, MD, DABFM
    CONFLICT OF INTEREST: None Reported
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    PPE donation websites
    L Olson, PA-C |
    Citizen led web resources working on getting donations of PPE to health workers:

    https://www.donateppe.org/

    https://getusppe.org/

    https://www.mask-match.com/

    https://ppelink.wordpress.com/

    https://docs.google.com/forms/d/e/1FAIpQLSdgEtdv00mF7Q9ve0e5Y4jvTKiWGFTCCCWZlasxnUuhS_-hLA/viewform

    Thank you!
    CONFLICT OF INTEREST: None Reported
    HEPA Filter Substitute & PAPR
    Larry McGrenera, BS Chemical Engineering | No affiliations, I am retired with working knowledge on personal filtration respirators
    The shortage of HEPA filters can be supplemented by using a painters full face dust mask ( I believe they are readily available to large purchasing groups) and replacing dust filters with HEPA filter cloth (it seems to be available online and pleated HEPA furnace filters could be used by laying the pleats flat). I also have an idea to create PAPR's by using portable CPAPs and the same HEPA filter. I am very mechanically oriented and would be happy to work with anyone in JAMA to work on both ideas.

    I can be reached at larmack1@gmail.com or
    708-942-4765 (leave a voicemail).
    CONFLICT OF INTEREST: None Reported
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    Finding rapid deployment of VHP sterilization
    Donna Kramer, MS Engineerings | Biohazard Lab Designer
    I have no microbiology, medical, or virology expertise but I am an engineer with experience in biohazard and animal research lab design. In many animal research facilities, vaporized hydrogen peroxide (VHP) decontamination chambers and/or rooms are included in the facility design. Biosafety cabinets, ventilated animal racks, and caging are typically what are decontaminated in these chambers in cases where steam sterilization is not feasible. Perhaps hospitals can share use of these animal equipment sterilization chambers until the shortage of PPE is resolved. The animal facilities may have greater VHP sterilization capacity than what currently exists in a hospital setting. Many university-based hospital systems also have animal research facilities, thereby improving the chances of rapid coordination and cooperation. Obviously SOPs would need to be developed to protect all workers and maintain viability of the ongoing animal studies, a number of which are also involved in Covid-19 research. Quickly constructing containment rooms or mobile/modular units for VHP decontamination that are in close proximity to the hospitals may also be an option.
    CONFLICT OF INTEREST: None Reported
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    NYC COVID Hotline
    parth patel, MD, PGY-3 Resident | Montefiore Medical Center/Jacobi Medical Center
    New York City (NYC) has a COVID hotline that gets calls from 311 or the H+H (Health + Hospitals) enterprise call center. At the moment, it is staffed voluntarily by Physicians, Residents (PGY-2 and above), Fellows, and Nurse Practitioners.

    We are addressing numerous callers daily in an impactful manner by providing clinical advice over the phone, alleviating patient anxiety and worries, and safely preventing overburden of emergency rooms, urgent care centers, and primary care clinics. While there are indeed patients who need to be directed for urgent medical evaluation, most patients from my limited experience just want advice
    and guidance as to what to do.

    Currently, the callers first get an automatic message that highlights the current testing protocol. Thereafter, the call is screened by a non-clinician at the call center. If the caller still wants to speak to a clinician, the volunteering providers are called in mass. The first provider to pick up the call and press any button on their keypad is the first to be connected, and the remainder are auto-disconnected. The cycle then continues with each new call. Shifts are available in 4 hour time slots. All providers are provided an ID number, should a patient want it for identification.

    This system may be a nidus for other cities to follow. Providers should not be discouraged from joining the fight against the COVID pandemic for fear of litigation. At least in New York, if there is any concern, I redirect providers to Subdivision (2) of section 6527, Section 6545, and Subdivision (1) of section 6909 of the Education Law.
    CONFLICT OF INTEREST: None Reported
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    Make your own high efficiency reusable viral filter mask
    Kameera Bopeththa, MBBS, MD, MRCEM | Teaching hospital Peradeniya. Sri Lanka
    As a small country, we are running out of our PPE especially N95 respirators. What could be the solution to keep our health staff safe? We have produced a tight -itting mask using ball guard ( please don't laugh) and small corrugated tube attached to the mask ( both are reusable). The open end of the tube is for the viral filter connection. We can breathe through this without significant resistance, though of course it id not like wearing a N95.
    CONFLICT OF INTEREST: None Reported
    Information and FAQs on Performance, Protection, and Sterilization of Masks Against COVID-19
    Moeed Azam, MD MBA | US Anesthesia Partners
    Information and FAQs on Performance, Protection, and Sterilization of Masks Against COVID-19 is available from Dr. Peter Tsai at:

    https://utrf.tennessee.edu/information-faqs-performance-protection-sterilization-of-masks-against-covid-19
    CONFLICT OF INTEREST: None Reported
    Excerpts from a physician post that appllies
    Tara Holahan, RN, BSN | Pediatric nurse
    A physician responding to the CDC recommendation that hospital staff use bandannas when masks run out:

    "Please don't tell me that in the richest country in the world in the 21st century, I'm supposed to work in a fictionalized Soviet-era disaster zone and fashion my own face mask out of cloth because other Americans hoard supplies for personal use and so-called leaders sit around in meetings hearing themselves talk. I ran to a bedside the other day to intubate a crashing, likely COVID, patient. Two respiratory therapists and two nurses were already at the bedside. That's 5 N95s masks, 5
    gowns, 5 face shields and 10 gloves for one patient at one time. I saw probably 15-20 patients that shift, if we are going to start rationing supplies, what percentage should I wear precautions for?

    Make no mistake, the CDC is loosening these guidelines because our country is not prepared. Loosening guidelines increases healthcare workers' risk but the decision is done to allow us to keep working, not to keep us safe. It is done for the public benefit - so I can continue to work no matter the personal cost to me or my family (and my healthcare family). Sending healthcare workers to the front line asking them to cover their face with a bandanna is akin to sending a soldier to the front line in a t-shirt and flip flops.

    I don't want talk. I don't want assurances. I want action. I want boxes of N95s piling up, donated from the people who hoarded them. I want non-clinical administrators in the hospital lining up in the ER asking if they can stock shelves to make sure that when I need to rush into a room, the drawer of PPE equipment I open isn't empty. I want them showing up in the ER asking "how can I help" instead of offering shallow "plans" conceived by someone who has spent far too long in an ivory tower and not long enough in the trenches. Maybe they should actually step foot in the trenches.

    I want billion-dollar companies like 3M halting all production of any product that isn't PPE to focus on PPE manufacturing. I want a company like Amazon, with its logistics mastery (it can drop a package to your door less than 24 hours after ordering it), halting its 2-day delivery of 12 reams of toilet paper to whoever is willing to pay the most in order to help get the available PPE supply distributed fast and efficiently in a manner that gets the necessary materials to my brothers and sisters in arms who need them.

    I want Proctor and Gamble, and the makers of other soaps and detergents, stepping up too. We need detergent to clean scrubs, hospital linens and gowns. We need disinfecting wipes to clean desk and computer surfaces. What about plastics manufacturers? Plastic gowns aren't some high-tech device, they are long shirts/smocks...made out of plastic. Get on it. Face shields are just clear plastic. Nitrile gloves? Yeah, they are pretty much just gloves...made from something that isn't apparently Latex. Let's go. Money talks in this country. Executive millionaires, why don't you spend a few bucks to buy back some of these masks from the hoarders, and drop them off at the nearest hospital.

    I love biotechnology and research but we need to divert viral culture media for COVID testing and research. We need biotechnology manufacturing ready and able to ramp up if and when treatments or vaccines are developed. Our Botox supply isn't critical, but our antibiotic supply is. We need to be able to make more plastic ET tubes, not more silicon breast implants. "
    CONFLICT OF INTEREST: None Reported
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    Protection by other means
    Michael Gorin, MD PhD | David Geffen School of Medicine UCLA
    A number of us in my department who have repeatedly attended biosafety training for our laboratory research are struck by the fact that our medical center (particularly in the outpatient setting) completely ignores a basic tenet of biosafety which is to have physical protective barriers. In most of our clinics the front desks are totally exposed leaving administrative staff struggling to serve patients and yet maintain safe distances. The construction of removable clear acrylic (plexiglass) shields that sit on the countertops offer significant protection without requiring distancing. This would reduce the demand for PPE by these staff. We have recently built such shields in the garage of one my colleagues and distributed them throughout the Department clinics. Others may find this useful in their own clinic settings
    CONFLICT OF INTEREST: None Reported
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    CleanPICC Technology: a new standard in maximum sterile barrier technique even in the most hostile medical environments and zero gravity
    Jaywant Parmar, MD | Radiology Associates of San Luis Obispo (multiple hospital affiliations)
    I am a mid-career clinical interventional radiologist working in small community hospitals on the California central coast.

    And, I have an idea.

    After family members developed complications of PICC placement early in my clinical career, I set off to improve the PICC placement procedure for the hostile single operator bedside environment, and even zero gravity.

    It has been quite a journey considering medical product development from my clinical perspective. At times, it has seemed like a "Wizard of Oz" type journey with many ups and downs and a lot of money sunk into
    a high-risk investment. But, I still believe in my idea and its merits. And, now we all have CoVID-19 to deal with.

    After a 10 year-long process, I was granted allowance of my US patent application 14/834,342 ( https://patents.google.com/patent/US20160096003A1/en ) somewhat ironically just last week, which outlines the novel "CleanPICC" technology. Briefly, the system uses magnets to deploy a PICC over a guidewire from within a sterile chamber directly into the bloodstream with no environmental exposure, and, then restraining the contaminated guidewire back into the chamber for safe disposal. 50cm guidewires are very cumbersome at the bedside, especially after blood contamination. Typical PICC lines are exposed for many minutes, possible greater than an hour, on the wards. Using CleanPICC, patient safety of the most vulnerable who need central access is enhanced. Provider PPE is enhanced. Contaminated medical waste is decreased as the sterile field needed is much smaller. Medical efficiency and effectiveness are increased. Please review an informational video on YouTube ( https://www.youtube.com/watch?v=AM1u_jdz9Ug ).

    I am now in the pre-production prototype phase of this technology for a 5F single-lumen PICC and have modified the delivery handle for manual actuation (it's not a robot, just a tube chassis with 2 magnetic sliders). I have sat in front of potential investors in the past who just cannot comprehend the need for this device or are skeptical of its benefits. This is certainly a problem in medical device development, and I am very much in favor of this excellent forum provided by JAMA in our time of need. I am still self-funded and have recently passed a milestone of the first 100 disposable units ready for a pre-production run under FDA 510k guidelines.

    I am seeking assistance from NIH, CDC and any other organization to rapidly advance the project. The goal of my unsolicited investigator-initiated research project is to rapidly mass-produce the novel central venous catheter delivery system for emergency medical use under FDA guidelines. I anticipate we could have 30,000 catheters and 300 delivery units in 60 days.

    I welcome any further questions and comments. I know that this device can save many lives over the upcoming months in the face of CoVID-19. As a clinical interventional radiologist, I have spent years considering this medical procedure in granular detail. The current standard of practice needs to be greatly modified under current medical conditions, I am sure you will agree. Please take a look at the links provided:

    US patent application (allowed with amended claims on 3/20/20)-
    https://patents.google.com/patent/US20160096003A1/en

    Informational video-
    https://www.youtube.com/watch?v=AM1u_jdz9Ug

    I need help to deliver this device to the frontline fast. In the meantime, ill do my best to manage our local PICC service.

    Jaywant Parmar MD
    jaywant.parmar@gmail.com
    805-400-8601
    CONFLICT OF INTEREST: I am the inventor of the patented technology and president of an LLC promoting its commercialization
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    Jounalist
    Chun fai Yung, BBA, MUP | TVB
    An FDA funding report in 2016 investigated reuse of N95s for 50 cycles without much loss in filtration efficiency or integrity of masks by treatments with hydrogen peroxide vapor (HPV) (1,2).

    REFERENCES

    1. https://www.fda.gov/emergency-preparedness-and-response/mcm-regulatory-science/investigating-decontamination-and-reuse-respirators-public-health-emergencies
     
    2. https://www.fda.gov/media/136386/download
    CONFLICT OF INTEREST: None Reported
    Barrier around patient to decrease personnel contamination
    Jacek Bochenski, MD | Children's Hospital of Philadelphia
    1. Intubation boxes have been proposed. A larger box over the entire patient or bed similar to neonatal isolation could significantly decrease personnel exposure and PPE use, particularly if openings to allow access to patients would be equipped with ”gloves” or sleeves creating a barrier.

    2. Plastic curtains like those used in construction or renovation could be used to isolate part of patient rooms. These would allow for eyeballing and IV lines could go from the patient part of the room to outside.
    CONFLICT OF INTEREST: None Reported
    Dutch sterilization protocol for N95 masks, reusable up to 5 times
    Huub Gelderblom, MD, PhD, MPH | Fred Hutchinson Cancer Research Center
    There is a 4 minute video from Dutch Technical University Delft about sterilizing and reusing FFP2 (European equivalent of N95) masks up to 5 times (1), a short report (2), and a piece from the University about how it came about (3).

    REFERENCE

    1. https://youtu.be/PumeDykuJt0 
    2. https://t.co/qQVvHrZGMc?amp=1
    3. https://www.tudelft.nl/en/2020/3me/march/tu-delft-works-on-reusable-surgical-masks-with-reinier-de-graaf-and-vsm/
    CONFLICT OF INTEREST: None Reported
    How to Reuse N95 Respirators and Other Masks in this Crisis
    Mark Clark, MD | John Muir Health Urgent Care
    Many (most?) clinics and medical centers are recommending that N95s be used as long as possible, but have not yet settled on a method for decontamination of the masks to prolong safe use. Wiping or spraying the masks with alcohols or other liquid disinfectants has the problem of degrading the mask material. The University of Nebraska is a notable exception, and has recently instituted a process using UV radiation (254nm) that will decontaminate their used N95's overnight.

    CDC, NIOSH and other institutions foresaw the possibility of pandemic-related PPE shortages and since at least 2005 have been
    investigating the problem of N95 respirator decontamination to allow safe reuse of these masks for HCWs.

    This information is available in the scientific literature, but to summarize there are at least three methods of N95/FFP respirator decontamination that are effective, adaptable to clinics and small hospitals, and that will not degrade the masks.

    1. UV method (UVGI). This has been reported on recently (Univ. of Nebraska, NYT, etc.) and involves the use of short wave UV (254nm) bulbs placed in proximity to the masks. The UV light source needs to be short-wave. Typically, something like a 40w low pressure mercury bulb is used. Total exposure time should be in the 5-15 minutes per side, depending on distance between bulb and masks. See Faulkner et al or Nebraska papers for details. This method would allow daily decontamination of all the N95 respirators used on a medical ward or large ICU in a large university hospital, and could be down-sized for use in smaller health care settings. Germicidal mercury lamps are readily available on the commercial market and are not expensive. Concerns about UV-C poor penetration beyond the surface layers of the respirators were allayed by the work of Fisher and Shaffer and others in 2009.

    2. Moist Heat incubation (MHI). N95 Masks incubated at 60 deg centigrade and 80% relative humidity for 30 minutes are effectively decontaminated, and the masks are otherwise unchanged. The mask needs to dry out overnight. In industrial applications this is done in a purpose built oven, but perhaps home or hospital ovens could be adapted.

    3. Microwave generated steam (MGS). This may be the most easily adopted method for us in this crisis since microwave ovens are ubiquitous. A standard 1100w microwave oven is used with a revolving carousel, and the masks are given 2 minuets exposure on high setting. Inside the oven is 50ml of tap water. Again, the masks are allowed to dry out overnight. While most N95 models have small metal crimps at the nose area, Faulkner et al (see below) did not observe any sparking during decontamination of the N95s using this method.

    I for one would welcome using a decontaminated N95 from yesterday rather than one that has just been sitting in a paper bag.

    REFERENCES

    Fisher and Shaffer J Applied Microbiol. 2009: https://sfamjournals.onlinelibrary.wiley.com/doi/pdf/10.1111/j.1365-2672.2010.04881.x

    John J Lowe et al Nebraska Medicine 2020

    Faulkner, Kimberly et al 2011: https://www.researchgate.net/profile/Kimberly_Faulkner/publication/51470842_Impact_of_Three_Biological_Decontamination_Methods_on_Filtering_Facepiece_Respirator_Fit_Odor_Comfort_and_Donning_Ease/links/54e5e3e90cf277664ff1b147/Impact-of-Three-Biological-Decontamination-Methods-on-Filtering-Facepiece-Respirator-Fit-Odor-Comfort-and-Donning-Ease.pdf
    CONFLICT OF INTEREST: None Reported
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    Why Adequate Protection is of Paramount Importance
    George Wong, MD LLM FACS FAHA FESO | The Chinese University of Hong Kong
    We have come through the crisis of potential shortage in PPE especially N95 respirators and surgical masks in Hong Kong in late January and February. The local healthcare profession rang the alarm in anticipation before registering the first imported case on 23 January 2020. The alertness is built on the tragedy of colleagues devastated or dead with SARS 17 years ago when disease transmission was still mysterious and colleagues fell down one by one until the adoption of stringent and vigilant protocols including use of N95 respirators. The situation then mirror what happens now in Italy and Spain. In local community, ways to reuse these masks and N95 respirators were discussed in the past 2 months amidst potential shortage and these reusable options are rejected as inevitably the quality of protection is reduced. One has to bear in mind that a compromise can mean a higher infectious risk to the healthcare profession, which in essence converted a healer to a patient, and when the frontline healthcare professional gets infected, a high viral dose can induce a severe disease even among the young and middle-aged healthcare professionals. As such, protection of healthcare profession is of primary importance and these should not be compromised when finding ways to reuse PPEs, masks, and respirators.
    CONFLICT OF INTEREST: None Reported
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    Use of Residential Convection Ovens to Extend Service Life of N95 Masks
    Joshua Lilienstein, MD |
    Circulating air in a convection oven may inactivate the SARS-CoV-2 (COVID-19) virus on N95 masks while causing only minor degradation of mask performance. The lowest achievable average temperature in many residential convection ovens is 77-100°C, and this offers an immediate means of virus inactivation. Preliminary data suggests that heating masks to this temperature for 35-40 min should be sufficient for viral inactivation, and incur low risk of damaging the mask. Accuracy of oven calibration will be critical to success. However there remain serious questions of risk vs. benefits, particularly the risk of viral spreading during the process. Experiments on actual masks are necessary to validate this proposal, and every such mask is one that will not serve in a clinical setting.

    Link to open access full text PDF:
    https://drive.google.com/file/d/109RIWIzjRT3ajXDsUopuFWcKe8OGvZFk/view?usp=sharing_eil&ts=5e7afe64

    Authors:
    William Hamburgen, Mechanical Engineer
    Joshua Lilienstein, MD
    CONFLICT OF INTEREST: None Reported
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    Low heat to sterilize
    Michael Brody, MD | Munster Community Hospital, Indiana
    We are starting to run out of PPE. So we are looking for ways to sterilize and reuse N95 masks and Tyvek coveralls and hoods.

    I believe easiest solution is dry heat. We are checking with our central processing to get their opinion. Hopefully their autoclave can go down to low temperatures. And if they can’t , I believe a residential cloths dryer should work (with validation of temperatures at low, medium, and high).

    Tell me what you think. All comments welcome.

    https://pubmed.ncbi.nlm.nih.gov/14631830/

    “were converted to be non-infectious after 90-, 60- and 30-min exposure at 56
    degrees C, at 67 degrees C and at 75 degrees C, respectively”

    56 c = 132.8 f x 90 min
    67 c = 152.6 f x 60 min
    75 c = 167 f x 30 min

    http://www.imcclinics.com/english/index.php/news/view?id=83

    Takeaway points:

    “1. It was found that dry heat disinfection (heating at 70 ℃ for 30 minutes) had the least effect on damaging the filtering mechanism, and the filtering effect could be maintained above 95%.”

    “4. The new coronavirus is sensitive to ultraviolet rays, and ultraviolet disinfection does not affect the filtration efficiency of respirators. However, the inactivation effect of viruses in mask fibers, which cannot be directly observed, is unknown. Therefore, it is not recommended.”

    http://www.fibermark.com/sites/default/files/FMK_DuPontTyvekUsersManual_0.pdf

    Tyvek melting point 275 f
    CONFLICT OF INTEREST: None Reported
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    Ventilator Open-Source Design - MIT-based team
    L Olson, PA-C |
    A MIT-based team of engineers, computer scientists, physicians, and others is working on an open-source ventilator design.

    “Almost every bed in a hospital has a manual resuscitator (Ambu-Bag) nearby, available in the event of a rapid response or code where healthcare workers maintain oxygenation by squeezing the bag. Automating this appears to be the simplest strategy that satisfies the need for low-cost mechanical ventilation, with the ability to be rapidly manufactured in large quantities. However, doing this safely is not trivial.” (1)

    “The researchers emphasize that this is not a project for typical do-it-yourselfers to undertake, since it
    requires specialized understanding of the clinical-technical interface, and the ability to work in consideration of strict U.S. Food and Drug Administration specifications and guidelines.” (2)

    “We encourage capable clinical-engineering teams to work with their local resources, while following the main specs and safety information, and we welcome any input other teams may have.” (2)

    “While it cannot replace an FDA-approved ICU ventilator, in terms of functionality, flexibility, and clinical efficacy, the MIT E-Vent is anticipated to have utility in helping free up existing supply or in life-or-death situations when there is no other option.” (1)

    “The all-volunteer team is working without funding and operating anonymously for now because many of them have already been swamped by inquiries from people wanting more information, and are concerned about being overwhelmed by calls that would interfere with their work on the project. ‘We would really, really like to just stay focused,’ says one team member. ‘And that’s one of the reasons why the website (https://e-vent.mit.edu/) is so essential, so that we can communicate with anyone who wants to read about what we are doing, and also so that others across the world can communicate with us.’ ” (2)

    REFERENCES

    1 https://e-vent.mit.edu/

    2 Chandler, David L. “MIT-based team works on rapid deployment of open-source, low-cost ventilator,” MIT News Office, March 26, 2020,
    http://news.mit.edu/2020/ventilator-covid-deployment-open-source-low-cost-0326
    CONFLICT OF INTEREST: None Reported
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    Retrofit and Quantitative Fit Testing of Expired Stock Duckbill N95 Respirators Using Tourniquet Material
    Ashiq Zaman, MD, MHA | University of Texas Health Science Center at Tyler
    On March 2, 2020, in order to address COVID-19-related respirator shortages, the FDA authorized emergency use by healthcare workers of NIOSH-approved filtering facepiece respirators for use by healthcare professionals beyond their manufacturer-recommended shelf life.

    We developed a protocol to utilize an expired (2010 stock) Kimberly-Clark Tecnol Fluidshield PFR95 N95 Particulate Filter Respirator whose elastic bands had lost their tensile strength.1-inch wide, latex-free tourniquet material was used to fashion two elastic straps to each corner of the duckbill style mask.

    The tourniquet material and respirator were precisely hole-punched and were attached using two, four-inch small zip-ties. After
    assembly, the respirator was donned by a test subject and a quantitative fit testing was performed. Fit testing demonstrated a fit factor of at least 95 for all tested conditions, including normal breathing (111, 95), deep breathing (106), head side-to-side (101), head up and down (136), talking (113), and bending over (113). Our procedure appears to update an otherwise defective N95 duckbill respirator into a functioning, sealed respirator for potential use as a protective means of last resort.

    We have since utilized an assembly line production scheme utilizing volunteer workers working at multiple stations to mass-produce these retrofitted respirators with marked success and throughput (up to 500-1000 retrofitted expired stock N95 respirators per day). Random samples of each half-daily production run have been quantitatively fit tested using a PortaCount quantitative fit testing machine with a 100 percent pass rate as of the time of publishing this commentary.

    Correspondence can be sent to: ashiq.zaman@uthct.edu
    CONFLICT OF INTEREST: None Reported
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    Protecting Health Workers in the COVID-19 PPE Market Collapse
    fabrizio bogliatto | Fabrizio Bogliatto, MD, PhD., Clara Occhiena, DON. Ivrea Civic Hospital, Ivrea – Torino, Italy
    As of March 29, 2020, the surveillance system launched by the Italian National Institute of Health collecting information on all people with COVID-19 throughout the country reveals 97.689 cases and 10.779 deaths, exceeding those registered in China. The number of people who recovered or were discharged from hospitals reached 13 thousand. The active cases progression is dramatic. In 2019, approximately 23% of the Italian population was aged 65 years or older. This older age distribution in Italy may explain, in part, Italy’s higher case-fatality rate compared with that of other countries. The health system in Italy has many private nursing homes (approximately 6.700 with more than 100.000 beds), the majority located in the north of Italy, that may become big clusters of COVID-19 infection. Nursing home residents are typically older adults with high levels of chronic illness and impairment. As such, they are particularly susceptible to severe complications and mortality from COVID-19. Unlike a hospital, a nursing home is someone’s home, without adequate infection control. In this scenario, many of the residents with respiratory symptoms will be transferred to the hospital in a few days, with a dramatic increment in admissions requiring intensive care. Similarly, many of the caregivers, getting sick, will have to stay home for a full quarantine period with a situation impossible to sustain. resulting in a massive transfer of residents in Italian hospitals.

    In Italy, the personal protective equipment (PPE) market is collapsed. Refill shipments are inadequate and health workers are experiencing high rates of infection and death partly because of inadequate access to PPE. Supplies are being distributed unevenly or are insufficient to meet demand. Facial masks are now available, since many factories are re-purposed to produce these supplies. Waterproof gowns for front-line health workers are lacking and the demand of these supplies will increase dramatically in the next days, according to the unpredictable rapid increase in ill COVID-19 patients.

    In crisis mode, unconventional solutions to protect health workers are acceptable. Waterproof gowns may be easily substituted by motorbike rain suits. These one-piece suits have a waterproof, polyurethane-backed nylon shell and sealed seam construction. They are washable with antiviral agents and reusable. This solution, just applied in an Italian hospital, has helped health workers otherwise exposed to infection get past despair.

    This solution may be applied also to the low income countries or in nursing homes with few caregivers.
    CONFLICT OF INTEREST: None Reported
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    Feasibility of reuse and disinfection of surgical masks in community setting during COVID-19
    Simon Lam, PhD, RN, FHKAN | The Hong Kong Polytechnic University
    According to the benefit of “masking” as a public health intervention (1) a published discussion paper highlighted the feasibility of reuse of surgical masks among the general public during this great shortage of surgical masks (2). Such a shortage forced many people to disinfect and reuse their used surgical masks. However, the guidelines for the methods were greatly unclear and the thought of “reuse” was objected by some of international health authorities. Indeed, mass masking would probably intercept the transmission link of COVID-19 when facing this novel epidemic with limited alternatives in the community setting.

    This article summarizes
    the different types of face masks, and reuse and disinfection methods published in various sources including published articles, and local and international authorities. More important, this review analyzed the existing disinfection methods in details with potential shortcomings and advantages, namely ultraviolet radiation, sunshine exposure, high temperature with or without steam and chemical (e.g., alcohol). The understanding of the structure (three layers), material (Polypropylene PP) and methods of filtration (i.e., inertial impact, interception, electrostatic attraction and diffusion) facilitated a better in-depth discussion and clear analysis. The current but preliminary evidence rejected the use of ultraviolet radiation (UVC) and sunshine exposure (UVA and UVB) because of doubtful of weak penetration power of UVC and poor disinfection power of UVA and UVB. The use of high temperature steaming (100°C) and 70% alcohol spray can certainly inactivate the coronavirus; nevertheless, the structure as well as the function of electrostatic attraction of mask filter would be damaged. Some evidence demonstrated that dry heat of 70°C for 30 minutes worked well, which maintained the PM 2.5 filtration efficiency and killed the virus effectively. Such discussion and analysis of current evidence posed a direction of further study, which validation of this suggestion deserved.

    References

    1. Leung CC, Lam TH, Cheng KK. Mass masking in the COVID-19 epidemic: people need guidance. The Lancet. 2020;395(10228):945.

    2. Lam SC, Huang EYZ, Suen LKP. Discussion on the feasibility of reuse and disinfection of disposable medical masks in novel coronavirus pneumonia. Journal of Nursing Administration. 2020;20:online first. Retrieved from http://subject.med.wanfangdata.com.cn/Topic/0563ec908c3b451e8361d18edeefbebd
    CONFLICT OF INTEREST: None Reported
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    CPAP, BI-PAP, APAP full and partial face masks,Tyvek filters
    Mike Bushroe, BS Math, Physics; MS Elec | None
    Building on the March 21 Cpap Full-face masks "bush" approach and Mar 23 Cpap full-face mask modification for replacing hose with a filter we should extend this to partial-face masks with some additions as well. To provide eye protection tape or glue on an eye shield large enough to stop direct flow droplets still moving from cough or sneeze and also to stop droplets now floating in the air. To do both the eye shield should reach up to the forehead and wrap around the sides almost to the ears to create still air space that droplets will rarely enter and move slowly if they due. If possible make the eye shield about goggle size and add foam strip around the entire edge to make a fairly air-tight seal. If the eye shield leaks add a piece of elastic attached at each side around eye level long enough to go around the head.

    Masks from more than just Cpap machines can be used. Bi-pap and Apap and other higher pressure systems almost all use full-face masks. In addition to general messages to the public asking for old masks you may also be able to contact the major Cpap supplies suppliers and ask them to send individual requests to customers they know already have old masks that they might be able to send in. HIPPA requirements will likely mean that only the suppliers will be able to know the names and addresses of current users. Some masks may also be available in thrift stores.

    For making your own air filters the Cpap and Bi-Pap machines usually use a small rectangle of Tyvek to screen out most of the small particles. Not all sources of Tyvek will be able to easily breathe through or too easy to breath through because they provide too little filtering effect. Some may be in between and require multiple layers to provide enough filtering. Cpap suppliers and some other companies may have backstock of the small, rectangular pieces of Tyvek that can be used for making filters or masks.

    Other possible filter materials may require making a mask out of two layers of fabric that are very easy to breathe through with one of these filter materials in between. They are: 1) coffee filters. These may be too hard to breath through. 2) Milk filters. Less commonly used to filter raw milk for people who milk their own cows. These would be very easy to breath through. 3) Vacuum cleaner bags. The disposable paper bags are designed to stop most medium to small particles but might be too hard to breath through. 4) Air filters for furnace/forced air systems. Some of the higher quality air filters, often with corrugated filter material would be able to trap most small particles and still be easy to breath through. Cut out a section about the size of a folded up mask, flatten the corrugations possibly with a clothes iron, mark top layer of cloth where each fold line was, sew the cloth-filter-cloth stack along each marked line, then pleat the mask along the original fold lines as much as possible and then sew the sides of the mask to reduce the mask to its final size and make the pleats permanent. 5) Automotive air filters. Same as previous, there should be many filters available and each one can make many face masks.

    While sterilizing masks with UV, remember that although direct sunlight is mostly visible and near-infrared, there is still a lot of UV as well. Not all window glass allows this UV to come through so hang the masks outdoors as much as possible.
    CONFLICT OF INTEREST: None Reported
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    Pracitcal Ozone Chambers maybe in your town already - Hockey Equipment Cleaners by Sanisport
    Jerry Kozak, BBA | None
    I own a hockey equipment cleaning business in Michigan, and my brother told me about this article / said that people were asking about practical ozone applications. We use a machine called a Sanisport Supreme, which floods a chamber full of equipment with ozone that it creates by arcing current through atmosphere. It's used by most major sports teams, and has been certified as effective against seasonal influenza and (I believe) even tested against MERS. The tests are published on their website / certifications are out of a testing facility in Montreal. I've offered ours to our local hospital and am awaiting their response. If you have a local hockey equipment cleaner, they may have one of these and not realize it's potential value in the fight. They are about $25,000 per machine, but they have no inputs outside of a 110v standard wall plug and air in the room - and can clean I'd think 100 masks or so in 10 minutes. A few big guys can transport one with a truck, and it's plug and play once you roll it into a facility.

    Sorry, I don't have any technical or medical training / nothing else to add, but you may have practical ozone sanitation chambers somewhere in your community, and the owners may not realize that they could be helping.
    CONFLICT OF INTEREST: None Reported
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    CPAP ResMed AirFit20 as Masks
    Susan Daicoff, MS (Clin Psych), JD, LLM | Retired Professor
    I’m using my CPAP ResMed AirFit F20 half-face masks with cotton Tshirt or paper towel filters placed between the plastic layers as COVID-19 masks. I did the research on the filter material and vacuum cleaner bags or HVAC filters would probably work better. There’s a tight seal and no aerosolizing (no unfiltered outflow), when repurposed and used without the fitting or tubing. (Could also cover with a cloth mask & use with a face shield or goggles for more protection.) This is easily washed & disinfected with bleach solution (or toss the paper towel filters). Saw two other comments on this. The materials are readily available. I had three old masks and headstraps sitting around. Has to be an improvement over masks without a tight seal. I’m a retired professor and the daughter of a (late) cardiovascular surgeon & professor. Dad trained or taught at Indiana U., U. Chicago, Mayo, U. Fla. He spoke often of working in the “TB sanitarium” in the '50s as a young doctor, and would have had much to say today. I hope this helps. Thanks for reading and for your consideration.

    Susan Daicoff
    Phoenix, Arizona
    sdaicoff@gmail.com
    www.susandaicoff.webs.com
    CONFLICT OF INTEREST: None Reported
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    BiPAP to invasive ventilator conversion using 3D printed T-piece adapter
    L Olson, PA=C |
    “In preparation for potential patient surge and shortage of critical mechanical ventilators for hospitalized COVID-19 patients, a Northwell Health physician, a respiratory therapist, and a 3D printing bioengineer have successfully designed the protocol to turn the more common bi-level positive airway pressure (BiPAP) machine into a functional invasive mechanical ventilator, through a 3D printed adaptor they also designed to aid in the conversion.” (1)

    “In addition to the T-piece adaptor, modifications to the BiPAP machine include the addition of two high-efficiency particulate air (HEPA) filters at both ends of the oxygen hose to alleviate fears of spreading the virus.
    They are also recommending using a blind reservoir connected to the last HEPA filter in the circuit. “ (1)

    “In an effort to help other hospital systems across the nation, Northwell Health will share the new protocols to convert the BiPAP machine as well as share the T-adapter 3D print design online.” (1)

    The team has posted videos of their work here:
    https://drive.google.com/drive/folders/1YA8wwh72UGzI1ExW3rHe0WsmGiLFnX0f

    REFERENCE

    1 Libassi, Matthew. “Northwell converts BiPAP machines into ventilators for hospitalized COVID-19 patients, uses 3D printed adapter,” Northwell Health Newsroom, March 31, 2020, https://feinstein.northwell.edu/news/the-latest/northwell-converts-bipap-machines-into-ventilators-for-hospitalized-covid-19-patients-uses-3d-printed-adapter
    CONFLICT OF INTEREST: None Reported
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    Save, renew, reuse
    Donald Bryant, B.Sc.Ch.Eg., MBA | Retired Environmental Engineer, Principal, Manager
    Owing to asthma, I have been reusing N95 masks that I use for air travel for many years based on anecdotal reports of protection during and following SARS 2003. I wear the mask for many hours during air travel, where I noticed an improved outcome for myself. In 2019, I needed more masks than I owned, for a project removing rodent habitat with potential hantavirus. I began a reuse of masks using a decontamination procedure. This is information only. It is not a recommendation or a warranty, nor is it a defensible study, and the effectiveness of the procedure should be confirmed by those with the capability. However I offer this as information in response to the urgent call. Adoption of the procedure is at the practitioners own risk.

    In Canada the government has listed effective hard surface sanitizing agents on their website along with the active ingredients. These commercial products use active ingredients which include sodium hypochlorite, hydrogen peroxide, benzalkonium chloride and some ammonium compound products. https://www.canada.ca/en/health-canada/services/drugs-health-products/disinfectants/covid-19/list.html#tbl1. Use on fabric masks is not discussed to my knowledge.

    My procedure is to soak the fabric portion of my N95 in a bleach solution, taking care not to inundate the elastic straps. After a few minutes, I rinse the mask and straps thoroughly with chlorinated tap water and set it out to dry. I keep two masks so that one can be used while the other dries overnight. I do not and would not share my mask with others, although I have heard a nurse say she does so, which is a sad state of affairs.

    The first step might be to stop disposing of every disposable PPE, where safe, prudent and practicable, in order to reduce waste and conserve the supply. In certain environmental projects, and in certain industry and construction it was common for workers to be assigned a reuseable half or full face respirator which they were then responsible for cleaning disinfecting and reusing. I simply adapted this strategy for my own purposes. It is not a final solution. It simply might extend the current supply until supply can catch up. This approach might be best adopted by the least vulnerable service providers so that front line staff do not have to do this. Followup by researchers familiar with medical requirements is recommended before adopting this approach. If a proven procedure arises, the masks would be available for it. Good Luck.
    CONFLICT OF INTEREST: None Reported
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    Evidence on dry heat method for disposal medical mask during COVID-19 in the community
    Emma Yun-zhi Huang, DPH, MPH | Macau University of Science and Technology
    Because of the outbreak of COVID-19, Chinese government adopted the strategies for ‘mass masking’ which means compulsory masks wearing in public places. It has been proved to be one of the effective strategies for reducing the incidence of COVID-19 after Chinese New Year. However, almost every Chinese people are lacking personal protective equipment (PPE), especially medical masks. Such great shortage of supply of medical masks forces the general public in Chinese thinking about reuse and decontamination methods.

    Fudan University Key Laboratory took an experimental test of dry heat inactivation influenza virus using hair dryer heating and baking at
    56℃ for 30 mins (1). Both Hair dryer and baking did not significantly affect the mask filterability in terms of ambient PM2.5. However, taking a hair dryer for 30mins for inactivation of virus only for one medical mask might be very inefficient. Another published discussion on the disinfection of medical masks suggested that home-based baking (i.e., dry heat) medical masks at 70℃ for 30 mins (preheat the oven before use) (2). This method will be more efficient in community setting. Storing the disinfected masks in a dry envelope or sealed bag after disinfection is ready to be used. Such method can cut down the consumption of masks for the entire society.

    Some published studies suggested a handmade protective screen using ‘Transparent plastic file bag’ plus handmade cotton masks are proposing for low risk community dwelling people.

    Reference:
    1. Song WH et al., Evaluation of heat inactivation of virus contamination on medical
    Mask. 2020; online first. Retrieved from
    http://jmi.fudan.edu.cn/CN/Y2020/V15/I1/31

    2. Lam SC, Huang EYZ, Suen LKP. Discussion on the feasibility of reuse and disinfection of disposable medical masks in novel coronavirus pneumonia. Journal of Nursing Administration. 2020;20: online first. Retrieved from
    http://subject.med.wanfangdata.com.cn/Topic/0563ec908c3b451e8361d18edeefbebd
    CONFLICT OF INTEREST: None Reported
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    Safer Intubation and Extubation - C- Arm Cover and Nasal Cannula
    Shailesh Kumar, MBBS. MD. | C K Birla group of hospitals. CMRI. Kolkata. Consultant Anaesthesiologist
    For intubation and extubation purposes The C- Arm cover can be used along with nasal cannula to protect the Intubator from the air blast from patient, in case PPE is not available.

    Settings – Hospital or a center where proper PPE is not available.

    Aim – To protect the Anaesthesiologists or the persons performing intubation, extubation , suction or other airway manouvers who are at highest risk of acquiring Corona infection due to close proximity to the patient .

    For intubation and extubation purposes wearing a C- Arm cover along with nasal cannula
    fixed over the face mask can be used to protect the Intubator from the air blast from patient .

    The nasal cannula is attached to an oxygen delivery source which delivers oxygen inside the plastic cover to the intubator.

    Special Preparation -

    1. Make 2 holes on sides of the C-Arm cover for the hands to come out.

    2. wear a gown and double gloves and other protective items.

    3. Place a nasal cannula over the N95 or any other mask before you wear the C- Arm cover .

    The nasal cannula comes out through a small hole made at back of the C-Arm cover .

    Use oxygen flow of 8-10 litres/ min .

    General preparations –

    1. Intubation tray [airway cart] to be ready.

    2. Colour coded drug lables to be used.

    3. Emergency drugs to be ready.

    4. Preoxygenation of the patient to be done in head elevated position.

    5. Full Muscle relaxion with either Rocuronium or Succinylcholine.

    6. After giving induction agents No bag mask ventilation to be done, to prevent aerosole formation.

    7. Intubation to be done .

    8. Position of the tube to be confirmed by another anaesthesiologist , doctor or nurse as stethoscope cannot be worn over the plastic cover.

    Benefits -

    This oxygen supply prevents suffocation of the intubator by not allowing CO2 level rising up inside.

    It also helps prevent fogging and improves visibility.

    More over, oxygen inside the cover creates positive pressure environment, So less entry of aerosols & also less fogging.

    This is highly cost effective and useful when proper PPE is not available.

    The photographs and other details can be provided on request.

    Dr Shailesh Kumar

    MBBS, MD.
    Consultant Anaesthesiologist
    shyicu@gmail.com
    Department of Anaesthesiology.
    0091-9304200081
    CONFLICT OF INTEREST: None Reported
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    Are Cloth Masks Really a Solution or Just a Way of Reassuring People?
    Maria de Lurdes Enes Dapkevicius, A. Professor Microbiology | University of the Azores
    As a microbiologist, I find deeply unsettling to contemplate a scenario in which health professionals would have to resort to DIY cloth (fabric) masks in settings where they would need to contact with an infected patient under the scope of the covid-19 pandemia. Not only these do not provide enough protection against the infectious particles, but they also create more opportunities for viral dispersion and staff contamination when storing used masks prior to sanitizing, washing and sanitizing them. These concerns are voiced in most of the literature that seriously addresses and properly tested this type of masks (see some links to relevant articles below). To me, it sounds like the governments/public institutions that recomend the use of these type of masks are merely admitting they were not prepared for a pandemic, notwithstanding the scientific warnings they received that one was brewing, and are simply recomending this kind of "PEP" to make people feel reassured, in the assumption that wearing these masks is "better than nothing", when in fact, it isn't. Not only they fail to protect the wearer, as they also increase the risk of contamination during reusage.

    Examples of relevant papers on cloth (fabric) facemasks that show the serious shortcomings of this type of protection are given below.

    REFERENCES

    https://bmjopen.bmj.com/content/5/4/e006577
    https://academic.oup.com/annweh/article/54/7/789/202744
    https://www.nature.com/articles/jes201642
    https://www.ijic.info/article/view/11366/8308
    CONFLICT OF INTEREST: None Reported
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    Household oven "sterilization" for re-use of N95 masks - exercise caution
    Michael Spedick, MD, FACS, FAAP | Ophthalmologist at Ocean Eye Institute, Toms River, NJ
    I have been re-using my N-95 mask for several days, since we only have a few left for the entire office, and tried to “disinfect” it using the oven technique described by Amanda Deskins, DO in a comment March 23 to the Editorial by Bauchner et al in JAMA https://jamanetwork.com/journals/jama/fullarticle/2763590 .

    Per instruction :
    MASK REUSE METHOD #2 - You can also sterilize the N95 mask by hanging it in the oven (without contacting metal) at 70C (158F) for 30 minutes—it is reported that COVID-19 cannot survive at 65C (149F) for 30 minutes. Use a wood clip to hang
    the respirator in the kitchen oven to do the sterilization.

    I used wood clothespins to suspend the mask in mid-oven of my Kitchen Aid Model KEBC167, closed the door, entered “bake”, “158 degrees” , “start” and watched the display announce “preheating”. Within a few minutes I watched the mask begin to melt.

    Based on this experience I would exercise great caution attempting this method.
    CONFLICT OF INTEREST: None Reported
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    PPE Supply and Demand Platform Using Blockchain and the IoT
    I-Jen wang, MD, PhD, EMHA | Taipei Hospital, Ministry of Health and Welfare; China Medical University; National Yang-Ming University; National Taiwan University,Taiwan
    In addition to reusing PPE, we suggest systems build a supply-and-demand platform using blockchain and the  Internet of Things (IoT). Developing a platform that hosts real-time interactive maps may show the locations of authorized factories that sell PPE and show how many they have in stock. The PPE map on the cloud platform would indicate what percentage of PPE are still in stock by a color-coded system. Customers may select a given area on the map with the cursor and know PPE availability by clicking on one of the colored bars. We have developed a face mask map in Taiwan (1). The map displays the name of the store, its location, opening hours, contact information, and the exact number of masks in stock.

    For other PPE, such as clothing, helmets, and goggles for hospitals, we will build a blockchain-based supply chain management system on a shared distributed ledger which provides an indisputable record of shipment, truck, and storage conditions.

    Blockchain is an exact record where all the communications among IoT devices are saved in the history (2). It provides immediate access to all the information about the products. Both the PPE companies and hospitals can track the entire product life cycle throughout the supply chain. The system will act like an online arrangement between all the PPE companies and hospitals involved in a trade. The conditions of the contract are written in computer codes to ease financial transactions. It can save labor cost and ensure data protection by eliminating paperwork.

    In the era of Industry 4.0, establishing a blockchain-based supply chain platform for resource sharing, information transparency, planning accuracy, inventory control, quality assurance, and customer services may help us combat emerging infectious diseases.

    Reference:

    1. Face mask supply and demand information platform. https://mask.pdis.nat.gov.tw/
    2. Sanjeev Verma. How blockchain and IoT is making supply chain smarter
    https://www.ibm.com/blogs/blockchain/2019/11/how-blockchain-and-iot-is-making-supply-chain-smarter/
    CONFLICT OF INTEREST: None Reported
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    UVGI Open Source Decontamination System
    Akiba Wang, BSEE, BS Applied Physics | Electrical Engineer
    We've put together an open source decontamination system based on Nebraska Medicine's publicly published protocol. It uses common components to build relatively strong UV light sources for decontamination.

    More information can be found at https://hackerfarm.jp/hyjeia
    CONFLICT OF INTEREST: None Reported
    Source of Reusable PPEs
    John Kossik, BS Chemical Engineering | Beacon Engineers
    The only way for a face mask to protect the user properly is for there to be an elastomeric seal between the mask and the skin. There is very large source of these that is being completely ignored: the nuclear industry. Here in Washington State there is the Hanford Site that was used to make nuclear weapons and whose mission mow is containment of waste generated over the last 60 years.

    The PPEs used in facilities like Hanford (and Savana River, GA as well as facilities supporting nuclear reactors) are reusable. They have facilities that wash the
    MSA Respirators that can clean 1000s of these masks at a time. They also do not use disposable coveralls; these too are washed for reuse. They have been doing this for decades and since these items are being cleaned for reuse for nuclear applications the cleaning is far, far more than would be needed for COVID-19.

    These cleaning facilities are probably operating at much smaller capacity than they did when I worked in the industry in the 1980s. The cleaning facilities probably now only run 1 shift and could probably increase their capacity by a factor of 3 in a matter of weeks if not days.

    In addition to equipment, people in the nuclear industry have been trained on how to properly put this equipment on and off without contaminating the wearer. These people would be valuable in instructing users on how to do this.

    The only problem here is the resistance of medical professionals from taking any input from people outside their industry. Hopefully this resistance can be overcome for the good of all.

    If you are interested I can put you in contact with people that still work in this industry that could help facilitate the application of nuclear industry PPEs to help in this situation.

    Thank you

    John Kossik
    jmk@63alfred.com
    CONFLICT OF INTEREST: None Reported
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    Emergency Resource Exchange
    Hardik Patel | Rheaply Inc. (Technology Startup)
    The Emergency Resource Exchange (ERx) is a new network for resource discovery and allocation, launched by Rheaply (Chicago) in collaboration with Northwestern University and in coordination with J.B. Pritzker's Office (Governor of the State of IL).

    ERx is a free-to-use online marketplace where hospitals, universities, manufacturers, and businesses can meet so that supply and demand can be made transparent network-wide - see https://outreach.rheaply.com/COVID19-response/

    Medical facilities needing supplies can browse listings, create requests, and receive notifications as respirators, face shields, ventilators, test kits, PCR machines, or other equipment becomes available.

    Organizations providing supplies can review requests or create listings
    for donations and sale. Transportation and delivery details can also be arranged with the platform’s built-in messaging system.

    CONFLICT OF INTEREST: None Reported
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    N95 Reuse Policy Should be Formalized ASAP
    Ian Cheong, MBBS, FRACGP, MBA | Springwood General Practice
    Stability of SARS-CoV-1 has been studied, in response to heat and UV (1). The same has not been done for SARS-CoV-2 to my knowledge.

    Stanford University tested N95 masks performance when heated to 75deg C for 30 mins (2).

    N95 reuse research is summarized at:

    https://www.n95decon.org/
    https://www.sages.org/n-95-re-use-instructions/

    REFERENCE

    1. https://www.ncbi.nlm.nih.gov/pubmed/14631830
    2. https://news.stanford.edu/2020/04/01/researchers-show-how-to-decontaminate-reuse-n95-masks/
    CONFLICT OF INTEREST: None Reported
    NASA-inspired face mask that can be made in seconds -- without sewing -- from readily available consumer materials
    ERIC Knight | Remarkable Technologies, Inc.
    Due to the COVID-19 emergency, my company published our preliminary research into an experimental NASA-inspired face mask that can be made in seconds -- without sewing -- from readily available consumer materials. See: https://lnkd.in/e4h4nvX
    CONFLICT OF INTEREST: None Reported
    Motorcycle Face Shields to Make Face Masks
    Alexa Zimmerman | No Medical Affiliation
    I hope this is allowed, if not please remove. I work at a Harley Davidson dealership and was thinking of using all donated helmets to make face masks to donate to local hospitals. But haven’t had much luck in finding instructions on how about doing do. If anyone could help that would be amazing. I want to do my part in providing protection to our amazing health care community!
    CONFLICT OF INTEREST: None Reported
    Alternative to N 95 mask
    Brett Bixby |
    My idea is a better alternative for the N 95 mask. I have 32 years of experience in the chemical industry. The masks we use are either full face or half face respirators that seal to your face and use cartridges to purify the air. The cartridges are designed to remove dangerous gases from the air and particulates. What I would like to have designed and manufactured is a UVC Air sterilizer that can be worn on the belt and powered by rechargeable batteries. The UVC Air sterilizer would be connected to the mask via a hose, replacing the cartridge. It would include adapters to fit various manufactures face masks. When the user takes a breath the air would be drawn into the enclosed UVC sterilizer, killing viruses and bacteria. The air is then pulled through the hose to the mask. One mask/sterilizer combo could replace hundreds of N 95 masks. A hospital would only need enough masks and UVC sterilizers for one shift. The mask can easily be separated from the UVC sterilizer, decontaminated and then be ready for the next shift.
    CONFLICT OF INTEREST: None Reported
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    Isolation devices and 3D printing in a time of covid-19
    Karen Jacqueline Cloete, PhD | University of the Western Cape
    Four local doctors at the Charlotte Maxeke public hospital in Johannesburg, South Africa have designed an isolation device. Termed the intubox or aerosol box originally used in Taiwan for sedated and intubated patients, the device covers the top part of the body from the shoulders upwards. Although the device is not a replacement for personal protective equipment, it protects healthcare workers from respiratory droplets from coronavirus patients. All openings are covered and the transparent and accessible protective device creates a seal around the patient within which all procedures take place. In other African regions, academics and researchers are also exploring the use of 3D printing technologies for the manufacturing of ventilators in collaboration with medical supply companies and engineers.
    CONFLICT OF INTEREST: None Reported
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    PPE Reprocessing
    Arthur McCoy, B.S. | San-I-Pak, Inc.
    Historically our equipment has solely been used to sterilize medical/infectious waste. As a part our state’s (California) Pandemic Preparedness Program in 2006, we realized the supply chain would be compromised during a true pandemic. As a result, we began testing with certain types of PPE (gowns, surgical masks, etc.). The results have been very successful. Our technology is now accomplishing two different tasks: sterilizing infectious waste and re-processing disposable PPE.

    We developed a PPE Guidance Document that we have prepared. In addition, other healthcare organizations have prepared their own SOP.

    Following is a media package that
    has covers the reprocessing off PPE.

    https://www.youtube.com/watch?v=699yRYL1uAA&feature=youtu.be
    https://fox40.com/news/local-news/tracy-companys-mobile-sanitization-units-to-aid-hospitals/
    https://www.kcra.com/article/how-a-tracy-business-is-helping-health-care-workers/32012455
    https://www.kcra.com/article/tracy-company-heads-to-nyc-to-help-health-care-workers/32136398
    CONFLICT OF INTEREST: We manufacture a technology that could be used to reprocess certain types of PPE
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    Homemade UVGI and heat chambers to address shortage of PPE N95 masks
    Felipe Barreta, PhD in Physics | State of Sao Paulo Scientific Police (Brazil)
    We are three crime scene investigators who wrote a document (independently from any country institution) to address the shortage of N95 masks in the public security service area, especially in the Forensics Crime Scene Investigation area.

    We originally wrote the document in Portuguese, and we translated it automatically to English using Google Translate.

    The text in English can be accessed at this link:
    https://docs.google.com/document/d/14J31X8OYAaJxy5KX5w_NI8QirfhDzVxUD-CdbRJk7q8/edit#heading=h.2kn55hh0dco0

    The texts in Portuguese can be accesed at this link:
    https://github.com/felipebarreta/Cartilha-de-Mitigacao-e-Prevencao-do-Covid-19-no-Trabalho-Pericial/blob/master/README.md
    CONFLICT OF INTEREST: None Reported
    Sanitizing NIOSH 'N95' Respirators with an inexpensively engineered high temperature steam autoclave
    Henry Pope | Pioneer Valley Chinese Immersion Charter School
    My son, Henry IV (age 13 in 8th grade), and I have spent the past seven days researching to develop a viable solution toward sterilizing NIOSH 'N95' type respirators.

    The key to our project was to develop a science-based and repeatable process that could be duplicated by any non-scientist.

    We made use of common household products which would require minimal if any investment to be successful.

    Our goal was to support multiple/bulk sanitization at once, of NIOSH 'N95' type respirators. While being effective, efficient, and safe.

    Video of our autoclave device with
    simplified construction and demonstration of use can be found at my YouTube channel here: https://www.youtube.com/watch?v=ervxrF-Ztmk&t=22s

    This process may be used by any persons or group to extend the functional and practical lifecycle of NIOSH 'N95' respirators.

    While additionally allowing for shared reuse of _sterilized_ N95 respirators, among essential staff in the event of severely limited supply access.

    ---

    Below are citations of the methods used in our process.

    Autoclave - Moist Heat

    “NIH Study Validates Decontamination Methods for Re-Use of N95 Respirators.” National Institutes of Health, U.S. Department of Health and Human Services, 15 Apr. 2020
    National Institutes of Health
    https://www.nih.gov/news-events/news-releases/nih-study-validates-decontamination-methods-re-use-n95-respirators

    “COVID-19 Decontamination and Reuse of Filtering Facepiece Respirators.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 9 Apr. 2020
    Centers for Disease Control And Prevention
    https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/decontamination-reuse-respirators.html
    CONFLICT OF INTEREST: None Reported
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