As Americans celebrate the rollout of a coronavirus vaccine, many of the doctors and nurses first in line for inoculation say a victory lap is premature. They fear that the optimism stirred by the vaccine will overshadow a crisis that has drawn scant public attention in recent months: the alarming shortage of personal protective equipment, or P.P.E., that has led frontline medical workers to ration their use of the disposable gloves, gowns and N95 respirator masks that reduce the spread of infection.
At St. Mary’s Medical Center in Duluth, Minn., health care workers who treat Covid-19 patients are required to reuse their tightfitting respirator masks up to six times before throwing them away. Although soiled N95s are sterilized each day with ultraviolet light, Chris Rubesch, 32, a cardiac nurse, says the masks invariably sag after two or three shifts, leaving gaps that can allow the virus to seep through. “Our days are filled with fear and doubt,” Mr. Rubesch said. “It’s like driving a car without seatbelts.”
Many of the shortages are the result of skyrocketing global demand, but supply chain experts and health care providers say the Trump administration’s largely hands-off approach to the production and distribution of protective gear over the past nine months has worsened the problem. That has left states and hospitals to compete for limited supplies. Price gouging has become the norm, and scores of desperate institutions have been duped into buying counterfeit products.
President Trump has made only sparing use of the Defense Production Act, a Korean War-era law that allows federal agencies to coordinate the distribution of scarce goods and force companies to prioritize government orders. The D.P.A. can also provide grants to companies that need help ramping up production.
In late January this year when medical glove importers in China heard whispers of a virus outbreak that could potentially have widespread consequences, they reached out to Top Glove, the world’s largest rubber glove maker.
At that time, phone calls to the Malaysia-based company were merely enquiries on delivery time and pricing. The calls didn’t turn into orders, said Lim Cheong Guan, Top Glove’s executive director, who heads the finance division, in an interview with FM.
“But things changed when the Chinese government started taking serious actions,” he said, pointing to city and province lockdowns that prevented workers from returning to offices and factories after the Lunar New Year holiday.
In February when the new coronavirus’s death toll surpassed that of 2003’s SARS outbreak, orders increased by 100% compared with the usual weekly orders from China. Singapore and, most recently, Italy had also started asking for more gloves.
In such a case of an unexpected surge in demand, how is Top Glove planning its production ramp-up?
It’s not that simple
The company produces 73.4 billion gloves a year and commands 26% of the global rubber glove market share. Its natural and synthetic rubber gloves are used by healthcare workers and food service workers, and in industrial settings. It sells to 195 countries, with the UK, Europe, and the US as its major export markets, closing 2019 with record revenue of MYR 4.8 billion ($1.16 billion) but a fall in profit due to increased competition and higher natural rubber prices.
The doubling of February orders means that it has to make roughly 5.8 billion more gloves in the coming weeks just to meet February’s additional demand. The usual lead time of 30–40 days was stretched to 50 days. This month when FM reached out again, orders are now 120 days till delivery, and its factories’ utilisation rate rose to 95%, up from 85% in February.
On the surface, a production ramp-up looks as simple as increasing inputs — raw materials, labour, and cash. But the experience of one manufacturer, Prestige Ameritech in the US, has shown that swift increases in production could create a risk that could almost destroy a business, according to a US National Public Radio report.
In 2009 at the height of the H1N1 flu pandemic, Texas-based Prestige Ameritech hired more workers and built new machines to increase surgical mask production. But the machines took months to complete, and by the time they were ready, the swine flu crisis had ended and demand had died out. To add to its woes, there was oversupply in the market, and hospitals didn’t buy for months. The manufacturer almost went bankrupt, NPR reported.
Protective equipment for healthcare workers is crucial to the fight against coronavirus. Earlier this month, the World Health Organization (WHO) urged businesses and governments to act swiftly to boost supplies of protective equipment, including gloves, medical masks, and respirators, for healthcare workers on the frontlines combating COVID-19, the disease caused by the new coronavirus. To meet rising global demand, the WHO estimates that manufacturers must increase production by 40%.
For many companies, production ramp-ups can be make-or-break moments. Winners are those that can act quickly to capitalise on the short but sharp demand spike. For Top Glove, the upshot has mostly been positive so far. In many ways, the company is well positioned to benefit from the demand surge.
New capacity every year
It already had a month’s worth of raw materials in warehouses to kick-start production ramp-up. And its rubber suppliers are in Thailand and Malaysia — the world’s largest and third-largest rubber producers, respectively — which means that Top Glove’s raw material supplies are secure amid current shocks to the global supply chains. A key factor now, Lim said, is to ensure that its suppliers in Thailand and Malaysia can also increase their raw material supplies to its factories.
Its factories run 24 hours a day in three shifts, and its 44 plants located mostly in Malaysia typically have 10% to 15% of unutilised capacity — a decisive factor that has enabled it to increase output at a moment’s notice.
The question is why do its factories run at an average 85% capacity for most of the year? Is it by design?
“We don’t target 85% [capacity]. We’d prefer 95% because it’s more efficient,” said Lim, the executive director of finance. “But because we build new production lines every few months, our capacity will continue to increase.”
“We’re the largest glove manufacturer in the world. We need to have extra capacity. We can’t run on 95% throughout the whole year,” he added.
“Situations like COVID-19 [are] not new to the industry,” said Shiv Dave, founder of Televisory, a Singapore-based consultancy. The industry has experienced the same situation during the SARS and H1N1 outbreaks, he said.
But since the SARS and H1N1 outbreaks, the labour market in Malaysia has changed tremendously. Across the industry, getting thousands of workers to fill production lines in the coming weeks will be an immense challenge.
In a recent note, a Maybank research analyst wrote that Top Glove’s sales volume will grow at a pace slower than its sales orders because production is constrained by a shortage of workers.
Malaysia’s rubber glove industry is heavily reliant on migrant labour from countries such as Indonesia, Nepal, Bangladesh, and Myanmar. Since last year, the country’s manufacturing sector has been experiencing acute labour shortages after the government imposed stricter labour requirements and cracked down on foreign workers without work permits. The move is to wean the sector off its dependence on low-skilled foreign labour as the country aims to become a developed economy.
“To balance increased capacity with workforce shortage, we estimate that the rubber gloves industry will require at least an additional 25,000 workers,” Dave said. “It’s a difficult task in the short term.”
Top Glove is also especially careful in managing workers’ hours. Two years ago, news surfaced that some of its factory employees worked an excessive number of overtime hours beyond what’s permitted under local labour laws, which the company denied. Lim, the head of finance, said that the company has improved its recruitment policy and that overtime hours are voluntary and “in accordance with what is permitted by labour laws”.
To sustain long-term growth, the company has turned to automation. It has been pouring investments into research and development to increase automation and efficiency in its lines. Ten years ago, it needed 15 workers for every million gloves produced. The number is down to 2.5 workers today, and it can go lower, Lim said.
Robotic arms have replaced human workers in pulling gloves off moulds and counting gloves. Workers are only needed at the end of the glove-making process to pack gloves in boxes.
A 4-month backlog
It’s largely a pull-demand strategy, where production is triggered by a customer’s order, instead of the traditional push-demand, where products are produced ahead of time according to projected demand. That means the company has avoided a glut in its warehouses. It has ready-stock available, but inventory is kept at a minimal level. But this strategy also means that there’s currently a four-month order backlog.
Lim, however, is not concerned with losing out to competition given that the virus has spread to more than 110 countries. Most glove makers are also operating at close to 100%. Last month, the WHO reached out to the Malaysian Rubber Glove Manufacturers Association, a local trade group, to receive assurance from Malaysia’s glove makers that they would increase production to prevent a global glove shortage.
“The industry is certainly in an oversold position right now but has not reached a pandemonium position yet,” said Denis Low, president of the glove manufacturers association, according to a local media report.
But to fill urgent orders, Top Glove is speaking to customers to see if priority can be given to countries that need gloves most at this time.
Being ready with sufficient raw materials, workers, and a credit line to tap into if it needs a cash infusion is all it can do — because predicting future demand is difficult given the nature of the pandemic.
“We can’t forecast demand because we don’t know how extensive or long this [virus spread] will be, and how much it has spread to other countries,” Lim said. “What’s important is to get ourselves ready, with lines prepared to process orders.”
He added if there’s a need for new capacity, the company plans to speed up installation of production lines in a new factory that is part of its yearly expansion.
Preparing for greater demand
But Lim said the company is well aware of a possible oversupply in the market when the pandemic subsides and is prepared for that likelihood.
“Down the road we may have issues of a slowdown effect because [customers] may have ordered excess stock, and they have to clear the stock,” he said. “During this good time, we must also prepare for what’s coming”.
At the company’s annual general meeting at the beginning of the year, Top Glove senior executives flashed a world map of glove consumption per capita on a huge screen. In a year, the US uses 150 glove pieces per capita, Italy 123 pieces, Japan 54 pieces, and China a comparatively minute six pieces.
Top Glove and other glove producers in Malaysia may already be supplying three in every five pairs used globally, but they are banking on increasing hygiene standards and awareness, healthcare reforms, and the world’s ageing population to drive growth in the industry. And those are promising prospects for which Top Glove is laying the groundwork.
The federal government has fallen well short of its goal to shore up an emergency stockpile of respirator masks and some other personal protective equipment for health workers amid the current surge in Covid-19 cases.
The Trump administration said in May it was aiming to increase its emergency supply of N95 respirator masks to 300 million in the coming 90 days. It never met the goal; by mid-November, the U.S. Strategic National Stockpile and the Federal Emergency Management Agency held 142 million N95 masks, which filter out at least 95% of small particles and fit snugly to the face.
The U.S. also has yet to develop a centralized database to distribute medical gear to all health providers. The Department of Health and Human Services hasn’t adopted key recommendations to ease supply shortages made in September by the U.S. Government Accountability Office. A federal crisis response program hasn’t reached its staffing goals for health responders.
The predicament “underscores the critical imperative” for HHS and FEMA to adopt September recommendations to address how it would deal with supply shortages and help states track supply requests, according to a new GAO report released Nov. 30.
HHS disagreed with the need to follow GAO recommendations on handling supply shortages. An HHS spokeswoman said some GAO proposals were vague, outdated and based on incomplete data. She said HHS has filled all supply requests made of the stockpile, that some states inflate their needs and that there haven’t been directives to deploy N95 respirators from the stockpile in the past 30 days.
The arrival of the Moderna vaccine brings hope to rural areas.
More nations close their doors to Britain as alarm grows over virus variant.
Governors impose new restrictions on travelers from Britain as holiday travel ratchets up.
Congress passes long-sought stimulus package.
As the world tries to contain a new strain of the virus, questions arise about how far it has already spread.
California builds field hospitals and considers rationing care as virus spreads unabated.
Armed protesters angry over virus restrictions try to force their way into the Oregon Statehouse.
A Florida scientist has sued state law enforcement in an ongoing battle over Covid-19 data.
Just one week after the first doses of a coronavirus vaccine were administered in the United States, a new batch of vaccines fanned out across the country on Monday, an urgently needed expansion of a vaccination effort that is expected to reach vulnerable populations and rural areas where hospitals are strained as soon as this week.
The vaccine, from Moderna, comes as the virus continues to spread virtually unabated: hospitalizations are over 115,000 for the first time, according to the Covid Tracking Project. Parts of California are down to their last I.C.U. beds and almost one-fifth of U.S. hospitals with intensive care units reported that at least 95 percent of their I.C.U. beds were full in the week ending Dec. 17. Nationwide, 78 percent of I.C.U. beds were full on average.
On Monday, confirmed cases in the country reached 18 million, just five days after surpassing 17 million on Dec. 16. The growth in cases appears to be leveling off: It took five days for the nation to go from 15 million to 16 million cases and then another four days to reach 17 million.
The total number of new cases on Monday was at least 201,720, with at least 1,960 new deaths.
And with Christmas and New Year’s on the near horizon, health officials fear that more travel will push those numbers even higher. More than a million travelers a day passed through American airport security checkpoints on each of the last three days, a spike in holiday travel that comes despite warnings from the Centers for Disease Control and Prevention.
Roughly six million doses of the newly authorized Moderna vaccine are being shipped to more than 3,700 locations around the country this week, adding to the nearly three million doses of the Pfizer-BioNTech vaccine that were dispatched mostly to health care workers starting last week. According to the Centers for Disease Control and Prevention, 614,117 doses had been administered as of Monday morning.
The Moderna vaccine, which can be stored in a normal freezer and comes in a smaller number of units than the Pfizer-BioNTech vaccine, offers particular hope for rural hospitals, which often do not have the ultracold equipment or staffing numbers to handle the Pfizer-BioNTech shipments. That vaccine requires an exceptionally low storage temperature of negative 70 Celsius and comes in units of 975 doses.
Many of the first vaccine shots went to health care workers. Joining them Monday were residents and staff members of hard-hit nursing homes, set to begin inoculating their residents through Walgreens or CVS this week, part of a deal struck with the federal government. These facilities have felt the brunt of the pandemic: At least a third of the nation’s deaths have been reported in nursing homes and long-term-care facilities, and many residents have been isolated from loved ones for much of the year.
OhioHealth, a hospital system in Columbus, Ohio, received 10,400 doses of the Moderna vaccine in ice-packed cardboard boxes on Monday. The hospital had already received nearly 2,000 doses of the Pfizer-BioNTech vaccine, and Dr. Joseph Gastaldo, an infectious disease specialist, rolled up his sleeve to get a dose of that vaccine on Monday morning. Not long afterward, he got the news that the Moderna shipment had arrived.
“We are all really exhausted both physically and mentally,” said Dr. Gastaldo, who said he asked to keep an empty vial of his vaccine as a keepsake. “Having everyone rally around being vaccinated offers a glimmer of hope.”
More than 70 rural hospitals in Texas are expected to receive the Moderna vaccine and start offering doses as soon as Tuesday.
“The burden is worse than it’s been in nine months,” said John Henderson, the chief executive of the Texas Organization of Rural & Community Hospitals. “Their staff is completely worn out,” he said. “The vaccine is the only optimistic news we’ve had in a few months.”
The Oregon State Hospital, a psychiatric hospital in Salem, also received its first shipment of the Moderna vaccine, and will begin vaccinating staff and patients next Monday, said Rebeka Gipson-King, hospital relations director.
Since the beginning of the pandemic, 11 patients and 65 staff members have tested positive for the virus at the state hospital. The hospital houses 579 patients on two campuses, and the pandemic has made many feel more isolated, said Ms. Gipson-King.
“This is a really big deal for us,” she added. “Just like everybody, the people who we serve at the state hospital, their lives have been disrupted.”
Silver Spring, MD — Global Nurses United is demanding stronger COVID-19 guidance from the World Health Organization, including a call for more personal protective equipment for health care workers and acknowledgement from WHO on how the virus is spread.
“Nurses and other health care workers in many countries still don’t have the personal protective equipment and basic safety precautions that they need to care for their patients safely,” reads a letter sent Nov. 19 – signed by nurses from 24 different countries – to WHO Director-General Tedros Adhanom Ghebreyesus. “Since January, WHO has … refused to recognize the amassing scientific evidence that SARS-CoV-2 is spread through airborne/aerosol transmission.”
The nursing organization is asking that WHO recommend optimal PPE, which includes a NIOSH-certified powered air-purifying respirator, coveralls incorporating head and shoe coverings that meet viral impenetrability standards, and medical grade gloves for those working directly with infected patients.
The minimum level of protection, according to GNU, should be an N95 single-use respirator, a face shield or goggles for eye protection, medical grade gloves, and a fluid-impermeable or resistant isolation gown.
GNU also asked WHO to strike down any recommendations regarding health care workers not needing PPE if they stay 3 feet from a COVID-19 patient, limiting PPE if they’re not in close contact with COVID patients, reserving N95 or other respirators only for aerosol-generating procedures, and allowing health care facilities to decontaminate and reuse N95s and other single-use PPE.
GNU, which includes Maryland-based National Nurses United, claims in the letter that WHO’s “weak guidance” on COVID-19 has left health care workers and patients more vulnerable during the pandemic. The letter also accuses WHO of failing to meet its moral and ethical obligation to patients and health care workers as stated in its values charter.
GNU is a federation of nurse and health care worker unions around the world that includes workers in the United States, Canada, Australia, India, Italy and Spain.