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On The Rationing Of PPE Gear, Masks And Everything Else

From the outset, the perceived need to ration our scarce resources seems to have driven the response to Covid-19. Rationing still appears to be limiting the ability of nurses and other frontline workers to access and routinely wear the PPE gear they need to do their job safely. Initially at least, we were also rationing the public’s access to Covid-19 testing. We also continue to pick and choose among the scientific evidence to justify advising the public against the need for them to wear masks…. If it hasn’t done so already, this trend will end up eroding public confidence in the Ministry of Heath assurances that hey don’t worry people, we have enough PPE gear, testing kits and masks to go around. Counter factual : if we’re rationing it, we haven’t got enough.

Obviously, rationing makes short term sense if we’ve been holding back our resources solely for the surge that’s likely to come. On testing access though, the rationing has put New Zealand out of step with how Singapore and Taiwan successfully went out early and hard, on mass testing. Presumably, we lacked enough reagent swabs to do likewise. If rationing is indeed the reality, then the public could accept that logic. But that hasn’t been the message given out. Being told there’s always been plenty to go around (with even more on the way) and then rationing the access to PPE gear (and initially to testing) can only undermine the public’s faith that the existing stocks and the future supply chains from India, China and elsewhere are as reliable as the MoH keeps on saying that they are.

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As this column noted yesterday, the MoH assurances seem particularly dissonant at a time when the overseas media is reporting so many examples of the PPE, ventilator and pharmaceutical supply chains being disrupted and overwhelmed, amid a rash of competitive bidding, hijacking of consignments and emerging shortages of the key ingredients for everything from PPE gear to the sedatives required to use ventilators. Has that order for an extra 30,000 face shields, 500,000 isolation gowns and 50,000 goggles actually landed in New Zealand yet ? For a fortnight now, there have been intimations from MoH that more ventilators have been ordered and more are on the way to boost our grossly inadequate stocks of these essential devices. Yet confirmation of their arrival continues to be elusive. So…have we clinched the deals on ventilators, or what ?

Ventilators involve a plastic tube being put down the patient’s throat, and this painful process requires sedating the patient beforehand. In the US, severe shortages are now emerging in the medications – fentanyl, versed, propofol etc – necessary to use the ventilators at all. How resilient are our stocks of those drugs? If we couldn’t go all out and do mass testing because of the need to conserve the key ingredients of the testing kits, it would be helpful to know if we have enough of the sedatives required to run our limited supply of ventilators for the prolonged period that this crisis will entail.

Masks, masks

As noted above, the MoH has been picking and choosing among the evidence on whether the public should be wearing masks. A week ago, MoH chief executive Ashley Bloomfield seemed to be placing much store on the US Center for Disease Control findings :

There is some suggestion that routine wearing of face masks when they're out in public may help reduce the transmission, for example, if they are asymptomatic - so we're looking very closely at that. I'm watching that CDC review very closely."

Yet when the CDC review came out in favour of the public wearing masks, the MoH switched to contrary advice from the WHO against wearing masks. Again, rationing appears to have been part of the reasoning. No one has a problem in prioritising the need for front line medical staff and workers in essential services to have the best masks. Yet the MOH is claiming that tens of millions of masks are being made here, and imported. If so, the public could surely have access to some of them.

Yes, wearing masks is not a risk free exercise. Fiddling with the masks to adjust them would involve an added touching of the face – and by its nature, a mask involves putting a potentially disease-catching device on your face. Even so, there is mounting evidence that wearing a mask can offer a limited amount of extra protection. Better than nothing, surely. The recent study linked to below is not only relevant to the debate about the wearing of masks by the public, but to the necessity for frontline health workers to wear PPE gear at all times around Covid 19 patients : 

In the latest World Health Organization recommendations for COVID-19, health care personnel and other staff are advised to maintain a 3-foot (1-m)6 distance away from a person showing symptoms of disease, such as coughing and sneezing. The Centers for Disease Control and Prevention recommends a 6-foot (2-m) separation.7,8 However, these distances are based on estimates of range that have not considered the possible presence of a high-momentum cloud carrying the droplets long distances. Given the turbulent puff cloud dynamic model, recommendations for separations of 3 to 6 feet (1-2 m) may underestimate the distance, timescale, and persistence over which the cloud and its pathogenic payload travel, thus generating an underappreciated potential exposure range for a health care worker. For these and other reasons, wearing of appropriate personal protection equipment is vitally important for health care workers caring for patients who may be infected, even if they are farther than 6 feet away from a patient.

Clearly, this warning applies to the public as well given the finding that Covid-19 ( like the flu, but even more so) could be being transmitted far further than 2 metre distances by the aerosols that people commonly exude when they breathe or talk - and not simply by the larger “droplets” expelled when they cough or sneeze, or as those droplets adhere to surfaces that people touch, and then touch their faces with contaminated hands.

Frankly, it seems kind of contradictory for the MoH to maintain the official line that masks provide essential protection for frontline workers, but are somehow of no use at all to anyone else. Obviously, surgical masks offer better protection than homemade ones. But as this 2013 study showed, even homemade ones are better than nothing. It found that a surgical mask filtered 89 percent of viral particles from volunteers’ coughs, a tea towel blocked 72 percent, and a cotton T-shirt blocked 50 percent of them. Thicker is better than thinner, and thorough washing after use is essential. Everyone also has to keep in mind that any masks made available to the public ( and especially the homemade ones) would offer only limited protection, and would not cover the eyes.

Warning : the ‘aerosols vs droplets’ argument is a rabbit hole down which you can disappear, and never re-emerge. This Atlantic magazine article by Ed Yong offers a great summary of the available evidence : and to a lesser extent, this Guardian article does a pretty good job, too. In sum, the MoH line on droplets being the main/only means of Covid-19 transmission looks to be increasingly untenable, and that has implications not only for the policy on the wearing of PPE and masks, but for the safe extent of social distancing. Here’s a key passage from the Atlantic article :

When researchers say a virus is “airborne,” like measles or chickenpox, they mean that it moves as aerosols. When the World Health Organization asserts that the new coronavirus is “NOT airborne,” it’s claiming that the virus instead spreads primarily through the close-splashing droplets, which either land directly on people’s faces or are carried to their faces by unwashed, contaminated hands.

Such messaging is “really irresponsible,” argues Don Milton, an expert in aerosol transmission at the University of Maryland. The scientific community doesn’t even agree about whether aerosol transmission matters for the flu, so “to say that after three months we know for sure that this [new] virus is not airborne is … expletive deleted,” he says. Milton and other experts who study how viruses move through the air say that the traditional distinction between big, short-range droplets and small, long-range aerosols is based on outdated science. Lydia Bourouiba of MIT, for instance, has shown that exhalations, sneezes, and coughs unleash swirling, fast-moving clouds of both droplets and aerosols, which travel many meters farther than older studies predicted. Both kinds of glob also matter over shorter distances: Someone standing next to a person with COVID-19 is more likely to be splashed by droplets and to inhale aerosols.

Wearing masks in public would therefore seem to make a lot of sense, given that climate. Given the asymptomatic nature of Covid-19 carriage, a mask makes even more sense. So does wearing PPE gear in any hospital room that contains known or suspected Covid-19 carriers.

Apps Away

A few days ago, the government was being accused of moving too slowly in adopting Singapore’s TraceTogether app for tracing the contacts by infected people. Here’s a useful description of how TraceTogether works. Basically, the app uses Bluetooth to create a log of the contacts made with other smart phone users, and this log can then be (voluntarily) be made available to Covid-19 tracing authorities.

Note : the app’s log records the contacts between users, and not their locations of contact. It answers ‘ who’ not’ where’ questions. Unlike GPS, TraceTogether reportedly performs well in dense urban settings and across various makes of smartphone device, provided users keep their Bluetooth function open at all times. Here’s how the app was developed by Singapore. Finally, some anonymising and timely data destruction measures were built into the system to meet the obvious privacy concerns about the misuse of the app for state surveillance.

Singapore, one would suspect, has a higher ratio of smartphone users with Bluetooth capacity than New Zealand. Still, the TraceTogether app could be made to work alongside the Health Ministry’s wider digital messaging about Covid-19 As MoH’s Ashley Bloomfield indicated yesterday, TraceTogether wouldn’t replace the need for the other, more conventional aspects of the tracing process, such as phoning – but it could usefully augment the tracing process, by ending the reliance on the fallible memory of infected people when it comes to the people with whom they may have been in contact. Reportedly, it will take another two weeks for Singapore to clear with New Zealand whatever is required to make the TraceTogether app widely available here.

Profiting from pandemics

Been wondering at all why US President Donald Trump has been pushing hydroxychloroquine so hard as a miracle cure for Covid-19? Here’s part of the answer :

Mr. Trump himself has a small personal financial interest in Sanofi, the French drugmaker that makes Plaquenil, the brand-name version of hydroxychloroquine.

And wouldn’t you know it, Sanofi is here to help : it has geared up to make millions of doses available. Other Republican leaders have also cashed in on their access to classified Senate Covid-19 briefings.

Sen. David Perdue of Georgia bought stock in a company that produces personal protective equipment (PPE) the same day the Senate received a classified briefing on the spread of the novel coronavirus, The Atlanta Journal-Constitution reported.

The report also documents 34 stock sales worth as much as $US825,000. The Journal-Constitution reported that Perdue’s portfolio activity from March onward was three times busier than it was in the last 13-month period before the coronavirus hit the United States.

Perdue has not been the only offender :

His counterpart in Georgia, Sen. Kelly Loeffler, sold off shares following the closed-door briefing on January 24. Sen. Richard Burr of North Carolina also unloaded stocks in the weeks after the briefing. Burr, in particular, has faced heightened scrutiny because of his trades and his position as chairman of the powerful Senate Intelligence Committee. The panel has access to the federal government’s most classified and sensitive information, and according to Reuters, Burr’s committee was getting daily briefings on the threat of the coronavirus around the time he dumped his stock.

Here’s the initial media reporting on how Senator Burr unloaded nearly $2 million in stock, after classified briefings gave him insider knowledge of what on what was coming. Wow. If only the White House and Republican senators had put us much energy and foresight into preparing the US public health system for the pandemic that was headed its way.

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