As the coronavirus disease 2019 (COVID-19) pandemic accelerates, global health care systems have become overwhelmed with potentially infectious patients seeking testing and care. Preventing spread of infection to and from health care workers (HCWs) and patients relies on effective use of personal protective equipment (PPE)—gloves, face masks, air-purifying respirators, goggles, face shields, respirators, and gowns. A critical shortage of all of these is projected to develop or has already developed in areas of high demand. PPE, formerly ubiquitous and disposable in the hospital environment, is now a scarce and precious commodity in many locations when it is needed most to care for highly infectious patients. An increase in PPE supply in response to this new demand will require a large increase in PPE manufacturing, a process that will take time many health care systems do not have, given the rapid increase in ill COVID-19 patients. In its current guidance to optimize use of face masks during the pandemic, the Centers for Disease Control and Prevention (CDC) identifies 3 levels of operational status: conventional, contingency, and crisis.1 During normal times, face masks are used in conventional ways to protect HCWs from splashes and sprays. When health care systems become stressed and enter the contingency mode, CDC recommends conserving resources by selectively canceling nonemergency procedures, deferring nonurgent outpatient encounters that might require face masks, removing face masks from public areas, and using face masks for extended periods if feasible. When health systems enter crisis mode, the CDC recommends cancellation of all elective and nonurgent procedures and outpatient appointments for which face masks are typically used, use of face masks beyond the manufacturerdesignated shelf life during patient care activities, limited reuse, and prioritization of use for activities or procedures in which splashes, sprays, or aerosolization are likely. When face masks are altogether unavailable, the CDC recommends use of face shields without masks, taking clinicians at high risk for COVID-19 complications out of clinical service, staffing services with convalescent HCWs presumably immune to SARSCoV-2 (severe acute respiratory syndrome coronavirus 2), and use of homemade masks, perhaps from bandanas or scarves if necessary. Many communities in the US and globally are rapidly entering crisis mode. Popular news outlets report unconventional solutions for PPE at local hospitals, such as plastic garbage bags for gowns and plastic water bottle cutouts for eye protection.2 Plans for resupply through the repurposing of industrial capacity and other means are welcome but seem unlikely to solve the shortage quickly enough as supply chains become more dysfunctional in the pandemic.3 The Department of Health and Human Services’ Strategic National Stockpile was created to solve precisely this problem, but its inventory is not transparent and news reports suggest its supplies are being distributed unevenly or are insufficient to meet demand.4 HCWs need supplies and solutions for these shortages now, and for that reason JAMA issued a call for ideas for how to address the impending PPE shortage.5 In the week since publication the article received more than 100 000 views and generated more than 250 comments. In addition, many additional ideas were sent directly to JAMA editors. The Box organizes the major themes of the contributions and the following discussion reviews several of them. A frequent proposal was to acquire PPE from existing supplies in non–health care industries and settings such as construction, research laboratories, nail salons, dentists, veterinarians, and farms, and redirect them to the health care system via charitable appeals, community organizing, financial incentives, or government mandate. One endeavor is Project N95, a national COVID-19 medical equipment clearinghouse to identify high-need regions and to source and distribute PPE and other equipment where it is needed most.6 Numerous proposals suggested sterilization of used PPE with agents ranging from ethylene oxide, UV or gamma irradiation, ozone, and alcohol. There were also novel proposals such as mask-fiber impregnation with copper or sodium chloride. These are not new ideas; work was performed after prior viral epidemics to determine the feasibility of sterilizing PPE.7 Most commenters acknowledged uncertainty about the effects of these sterilizing agents on the structural integrity of PPE, and there is some evidence the fibers in masks and respirators that filter viral particles can degrade and lose their efficacy with PPE reprocessing.7 A few people advocated for use of positive pressure airflow helmets; proposals ranged from creating devices from plastic bags insufflated using compressed air and nasal cannula tubing to adoption of commercially available devices used in the welding industry. An advantage of this approach is that by not relying on filters, positive airflow devices can be cleaned and reused indefinitely. Many proposals reflect an era when PPE was made of cloth and laundered.8 Health care might be made greener if reusable PPE was employed where feasible. Cloth gowns and masks are easily created and stored, and laundry capacity could easily be expanded by recruiting commercial launderers that service hotels and other large organizations who currently sit idle. Many contributors wrote of sewing masks, creating them out of clothing, using novel materials to make them, and using cloth Editorial Opinion

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在 COVID-19 大流行期间采购个人防护设备

随着 2019 年冠状病毒病 (COVID-19) 大流行的加剧，全球卫生保健系统因寻求检测和护理的潜在传染性患者而不堪重负。防止感染在卫生保健工作者 (HCW) 和患者之间传播取决于有效使用个人防护设备 (PPE)——手套、口罩、空气净化呼吸器、护目镜、面罩、呼吸器和防护服。所有这些的严重短缺预计将在高需求地区发展或已经发展。PPE 以前在医院环境中无处不在和一次性使用，现在在许多地方是一种稀缺且珍贵的商品，当它最需要照顾高传染性患者时。为响应这种新需求而增加 PPE 供应将需要大量增加 PPE 制造，鉴于 COVID-19 患者的迅速增加，许多医疗保健系统都没有这个过程需要时间。疾病控制与预防中心 (CDC) 在其当前的大流行期间优化口罩使用指南中确定了 3 个级别的操作状态：常规、应急和危机。 1 在正常时期，口罩以常规方式使用保护医护人员免受飞溅和喷溅。当医疗保健系统面临压力并进入应急模式时，CDC 建议通过有选择地取消非紧急程序、推迟可能需要戴口罩的非紧急门诊、从公共区域取下口罩并在可行的情况下延长使用口罩来节省资源。当卫生系统进入危机模式时，CDC 建议取消通常使用口罩的所有选择性和非紧急程序和门诊预约，在患者护理活动期间使用超出制造商指定保质期的口罩，限制重复使用，并优先使用有飞溅的活动或程序，喷雾或雾化是可能的。当完全没有口罩时，CDC 建议使用不带口罩的面罩，使处于 COVID-19 并发症高风险的临床医生停止临床服务，为可能对 SARSCoV-2（严重急性呼吸系统综合症冠状病毒 2）免疫的恢复期医护人员配备人员服务)，并使用自制口罩，如有必要，可以使用头巾或围巾。美国和全球的许多社区正在迅速进入危机模式。5 在发表后的一周内，这篇文章的浏览量超过了 100 000 次，并产生了 250 多条评论。此外，许多其他想法直接发送给 JAMA 编辑。The Box 组织了贡献的主要主题，下面的讨论回顾了其中的几个。一个常见的提议是从建筑、研究实验室、美甲沙龙、牙医、兽医和农场等非医疗保健行业和环境中的现有供应品中获取 PPE，并通过慈善呼吁、社区组织、财政激励或政府授权。一项努力是 N95 项目，这是一个国家 COVID-19 医疗设备信息交换所，用于确定高需求地区，并在最需要的地方采购和分发 PPE 和其他设备。6 许多提案建议使用环氧乙烷、紫外线或伽马辐射、臭氧和酒精等试剂对使用过的 PPE 进行消毒。还有一些新颖的建议，例如用铜或氯化钠浸渍面罩纤维。这些都不是新想法；在之前的病毒流行之后进行了工作，以确定对 PPE 进行消毒的可行性。 7 大多数评论者承认不确定这些消毒剂对 PPE 结构完整性的影响，并且有一些证据表明口罩和呼吸器中过滤病毒颗粒的纤维可以PPE 再处理会降低并失去其功效。7 一些人主张使用正压气流头盔；提案范围从使用压缩空气和鼻插管充气的塑料袋制造设备到采用焊接行业中使用的市售设备。这种方法的一个优点是不依赖过滤器，可以无限期地清洁和重复使用正气流装置。许多提案反映了 PPE 由布制成并经过洗涤的时代。8 如果在可行的情况下使用可重复使用的 PPE，医疗保健可能会变得更环保。布质长袍和口罩很容易制作和存放，而且可以通过招募为酒店和其他目前闲置的大型组织提供服务的商业洗衣工来轻松扩大洗衣能力。许多撰稿人写了缝制面具，用衣服制作面具，使用新颖的材料制作面具，并使用布料编辑意见 这种方法的一个优点是不依赖过滤器，可以无限期地清洁和重复使用正气流装置。许多提案反映了 PPE 由布制成并经过洗涤的时代。8 如果在可行的情况下使用可重复使用的 PPE，医疗保健可能会变得更环保。布质长袍和口罩很容易制作和存放，而且可以通过招募为酒店和其他目前闲置的大型组织提供服务的商业洗衣工来轻松扩大洗衣能力。许多撰稿人写了缝制面具，用衣服制作面具，使用新颖的材料制作面具，并使用布料编辑意见 这种方法的一个优点是不依赖过滤器，可以无限期地清洁和重复使用正气流装置。许多提案反映了 PPE 由布制成并经过洗涤的时代。8 如果在可行的情况下使用可重复使用的 PPE，医疗保健可能会变得更环保。布质长袍和口罩很容易制作和存放，而且可以通过招募为酒店和其他目前闲置的大型组织提供服务的商业洗衣工来轻松扩大洗衣能力。许多撰稿人写了缝制面具，用衣服制作面具，使用新颖的材料制作面具，并使用布料编辑意见 8 如果在可行的情况下使用可重复使用的 PPE，医疗保健可能会变得更环保。布质长袍和口罩很容易制作和存放，而且可以通过招募为酒店和其他目前闲置的大型组织提供服务的商业洗衣工来轻松扩大洗衣能力。许多撰稿人写了缝制面具，用衣服制作面具，使用新颖的材料制作面具，并使用布料编辑意见 8 如果在可行的情况下使用可重复使用的 PPE，医疗保健可能会变得更环保。布质长袍和口罩很容易制作和存放，而且可以通过招募为酒店和其他目前闲置的大型组织提供服务的商业洗衣工来轻松扩大洗衣能力。许多撰稿人写了缝制面具，用衣服制作面具，使用新颖的材料制作面具，并使用布料编辑意见