Iowa braces for PPE shortage, but officials say the curve is flattening

Army trainers show NHS doctors and nurses how to put on Personal Protective Equipment (PPE) during the 2014 ebola outbreak. — Simon Davis/DFID

The Iowa Department of Public Health issued an personal protective equipment (PPE) order on Friday to address current and anticipated shortages of the urgently needed supplies.

The order calls for health care providers to minimize patient contact when possible, shorten the stay of COVID-19 patients in hospitals where PPE is in short supply and reuse normally single-use PPE in the case of extreme shortages.

Gov. Reynolds already banned elective and nonessential medical and dental procedures to preserve PPE on March 26, and IDPH has previously issued guidelines to health care providers about prolonging the use of PPE.

“Unfortunately, we’re in a position where, like many states and countries across the globe, we are preparing for a time when we might not have enough of these supplies,” said IDPH Deputy Director Sarah Reisetter during the governor’s Friday press conference on the state’s response to COVID-19.

Reisetter outlined what is included in the order, which she said is based guidelines from the Centers for Disease Control and Prevention.

“The order applies to healthcare providers, hospitals, healthcare facilities, clinics, local public health agencies, medical and response organizations and any others who use PPE for the treatment of patients or residents of facilities,” Reisetter said. “The order requires these entities to decrease demand for PPE by minimizing patient contacts when possible and maximizing the way barriers and ventilation systems are used.”

The second part of the order, Reisetter said, “is focused on extending the use of PPE, when the demand for PPE exceeds supply.”

It requires health care providers and facilities “to use face masks that may be beyond their shelf-life or expiration date, not change face masks or respirators for each patient encounter, use washable gowns, use reusable eye protection, decrease the length of stay for COVID-19 patients, if they are medically stable.”

“The third step in the order, if PPE use continues to outpace supply, is to implement crisis capacity standards,” Reisetter continued. “This would include reusing PPE and provides guidance for removal and reuse, using PPE past its shelf-life, prioritizing face masks for essential activities that may involve direct infectious contacts, and considering alternative approaches, such as using homemade masks in combination with face shields.”

The order also provides legal immunity to providers and facilities that act in accordance with its guidelines.

“We understand the issuance of this order may be unsettling, but due to the global shortage of PPE supply, we’ve determined that now is the time to take this action,” Reisetter said.

According to Reisetter, “facilities are already doing some of the extended use guidelines, because there has been a shortage.”

Reynolds has been repeatedly asked at her press conferences whether the state was having difficulties acquiring necessary medical supplies from the federal government’s national stockpile, or being outbid for supplies on the open market. The governor has evading answering those questions, typically replying that Iowa doing the same thing other states are to acquire supplies.

On Friday, Reynolds gave a fuller answer to the question when asked if the state was having trouble getting PPE from the federal government as the national stockpile becomes exhausted.

“We’ve seen it all along,” she said. “We were receiving some orders [from the national stockpile], but as we continue to see those pushed back, we’ve had to reach within the state to see what else we can do to help to provide our healthcare workers and first responders the PPE that they need.”

Reynolds highlighted in-state efforts, such as the Iowa Department of Correction’s use of prison labor to produce PPE. She said prisoners have so far made 28,000 gowns, and are increasing their production rate.

The question of how IDPH is determining whether Iowa is seeing a “flattening of the curve” in the spread of COVID-19 was also raised at the governor’s Friday press conference. On Thursday, both Reynolds and Reisetter said the curve was flattening, even though IDPH reported the biggest one-day increase in the number of COVID-19 cases that day.

Reisetter said the graph she was referring to wasn’t one documenting new cases.

“What we have been looking at is onset of symptoms data,” she said.

This epidemiological curve is the one Reisetter and Reynolds have been referencing.

“When we look at our onset of symptoms data, that appears to be flattening,” Reisetter said.

Reisetter didn’t explain why IDPH is relying on the epidemiological curve, as opposed to other graphs that rely on other datasets. But the New York Times recently published a story on epidemiologists using onset of symptoms data.

The data helps show “just how far behind the virus we are,” said Justin Bahl, an associate professor of infectious disease and epidemiology at the University of Georgia, “and, potentially, how much more transmission is happening in the community before we can identify and isolate those people.”

Looking at the date patients’ symptoms started tells epidemiologists more about the true progression of an outbreak than confirmed case numbers alone. That’s because there are often lags between the moment someone is infected, when they fall ill and when they receive a positive test result.

But the Times noted an important limitation to this approach.

This data shifts public understanding of the U.S. epidemic curve days to weeks earlier, but it still does not reflect the true scale of Covid-19 cases in the country. The symptom onset data is based on patients who tested positive and misses cases that are treated at home and others that may not receive testing.

Responding to a question, Reisetter acknowledged that testing has been very limited in Iowa, and that may affect the quality of analysis. Still, IDPH continues this approach to be the most useful in determining the spread of the virus.

“Despite our limited testing, we have not continued to see a tick up in terms of the date of the onset of symptoms,” Reisetter said.

IDPH hasn’t released any onset data to the media or the public, but the governor said the department will begin to do so next week.

On Friday, IDPH reported another 118 Iowans have tested positive for COVID-19, including 14 residents of Johnson County and 10 residents of Linn County.

• Allamakee County, 1 middle-age adult (41-60)

• Black Hawk County, 6 adults (18-40 years), 7 middle-age adults (41-60 years), 1 older adult (61-80 years)

• Cedar County, 1 adult (18-40 years)

• Clarke County, 1 middle-age adult (41-60 years)

• Clayton County, 1 adult (18-40 years)

• Clinton County, 2 middle-age adults (41-60 years), 1 older adult (61-80 years)

• Dubuque County, 1 middle-age adult (41-60 years)

• Fayette County, 1 middle-age adult (41-60 years)

• Harrison County, 1 older adult (61-80 years)

• Henry County, 1 adult (18-40 years), 1 older adult (61-80 years)

• Jasper County, 1 adult (18-40 years)

• Johnson County, 1 child (0-17 years), 5 adults (18-40 years), 6 middle-age adults (41-60 years), 2 older adults (61-80 years)

• Linn County, 3 adults (18-40 years), 4 middle-age adults (41-60 years), 2 older adults (61-80 years), 1 elderly adult (81+)

• Louisa County, 5 adults (18-40 years), 6 middle-age adults (41-60 years), 3 older adults (61-80 years)

• Marshall County, 2 adults (41-60 years)

• Muscatine County, 2 adults (18-40 years), 8 middle-age adults (41-60 years), 1 older adult (61-80 years)

• Osceola County, 1 middle-age adult (41-60 years)

• Polk County, 6 adults (18-40 years), 1 older adult (61-80 years)

• Pottawattamie County, 1 middle-age adult (41-60 years)

• Scott County, 3 adults (18-40 years), 6 middle-age adults (41-60 years), 1 older adult (61-80 years, 1 elderly adult (81+)

• Tama County, 4 adults (18-40 years), 3 middle-age adults (41-60 years)

• Union County, 1 older adult (61-80 years)

• Wapello County, 1 adult (18-40 years)

• Warren County, 1 adult (18-40 years), 1 middle-age adult (41-60 years)

• Washington County, 2 adults (18-40 years), 2 middle-age adults (41-60 years), 1 older adult (61-80 years)

• Winnebago County, 1 adult (18-40 years)

• Woodbury County, 3 middle-age adults (41-60 years)

The newly reported cases bring the total number of Iowans who have tested positive for the virus to 1,388. Linn County has had 225 residents test positive and Johnson County has had 185.

IDPH also reported two more deaths on Friday. Both of the deceased were residents of Linn County, one was between the ages of 61 and 80, the other was older than 81.

Iowa’s total number of COVID-19 fatalities now stands at 31.

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