You are called to attend an emergent cesarean delivery at term for decreased fetal movement. The mother has a cough and a fever and a pending coronavirus disease 2019 (COVID-19) test. As you prepare, you look for a new N95 mask, but there are none to be found.

Many of you do not need to imagine this scenario because, during this pandemic, it has been your reality. Do you have an N95 mask to wear? Did you early on, at the start of the pandemic? Have you worn it for patient care already? What about use for multiple patients, over multiple days, although the majority of N95 masks are designed to be discarded after a single use (SU)?

The COVID-19 pandemic has brought extraordinary challenges to the practice of health care. Providers have had to adapt to changes while striving to uphold standards of safety for themselves, their patients, and their patients’ families. Not all providers have had what they need to stay safe. Limited supplies of N95 masks and other personal protective equipment (PPE) have cost the lives of health care professionals all over the world. Although this has been a new experience for many in well-resourced settings, this pandemic brings to light a grim reality that colleagues in low-resource settings (LRSs) know well. Beyond a lack of PPE, the shortage of essential daily resources needed to provide safe, lifesaving care adds to glaring global health disparities.

Shortage of trained personnel and essential lifesaving equipment contribute to blatant disparities in neonatal and child mortality.1  Perinatal events (birth asphyxia), prematurity, and infection are the leading causes of neonatal mortality and are in the top 5 causes of mortality for children aged <5 years.2  Helping Babies Breathe (HBB), an instructional neonatal resuscitation program designed for LRSs, is celebrating 10 years of success reducing rates of neonatal mortality and fresh stillbirth through training birth attendants.3  HBB advocates for a trained birth attendant to be present at every delivery, wherever it may occur. However, the availability of clean, functional equipment poses a dangerous gap between well-trained birth attendants and their successful management of a life-threatening neonatal event. The second edition of HBB includes recommendations for disinfection of reusable equipment in LRSs; however, this does not fully address these challenges.4  Firsthand experience from a delivery hospital in Kenya will illustrate these barriers.

First, although the reprocessing recommendations, published by the global health nongovernment organization PATH, address the disinfection of reusable neonatal resuscitation equipment, outstanding questions exist regarding whether SU equipment can be reprocessed safely.5,6  In well-resourced settings, this is not an issue. Imagine: a pediatric team attending a delivery will often prepare by opening a new resuscitation mask and bulb suction device. The infant is delivered active and crying and the opened but unused mask and bulb suction device are discarded. In LRSs, SU equipment is too valuable to be thrown away; it is often reused, becoming a potential vector for transmission of infection. Even damaged equipment may be kept in use for patient care because of lack of other options.7 

Second, many LRSs face barriers to procuring needed medical supplies.8,9  All supplies reach LRSs through humanitarian, corporate, and/or government vendors. There are many hurdles to the successful functioning of these supply chains, including cumbersome regulatory policies, funding, and communication.8,9  Midwives in Kenya describe difficulty finding corporate vendors who will sell affordable, reusable equipment and reliably help them navigate import fees, shipping, and customs.

Supply chain challenges create equipment shortages on a busy delivery ward in rural Kenya and cause staff significant daily stress. Authors report from personal experience that midwives frequently attend consecutive deliveries in which specific interventions are indicated (eg, urgent suctioning to clear a newborn airway). If all the suction bulbs are used up, the midwife may be left hastily trying to clean the soiled bulbs to have one ready for the next infant. The midwife faces impossible choices between reusing unclean equipment to help an infant breathe and risking infection or even death.

We have identified 4 recommendations that may help address these inequities: implementing and supporting sustainable and effective reprocessing, empowering frontline innovations, advocating for ethical and transparent equipment donation, and supporting local and equitable corporate supply chains.

The PATH reprocessing guideline is an important first step in addressing this important and oft-neglected issue. When possible, the PATH guideline should be implemented for optimal reprocessing of reusable equipment.4,5  However, it relies on several resources still limited in many LRSs, including reliable, reusable equipment supplies, clean water, trained personnel, and dedicated reprocessing space.5,6  SU equipment poses challenges. For example, the commonly used, SU blue bulb suction device cannot be opened to adequately disinfect the inside, which may increase nosocomial transmission of infections. It will be challenging and at times ethically problematic to create disinfecting guidelines for SU equipment. However, this is not dissimilar to challenges faced by hospitals around the world during the COVID-19 pandemic, trying to conserve PPE by finding ways to safely reprocess it.10  More work is needed with frontline providers to develop, implement, and support sustainable reprocessing.

Within a short time after the arrival of COVID-19 at the authors’ hospital in rural Kenya, the government-supplied PPE stock dwindled. Staff quickly adapted certain items so each frontline provider could have adequate PPE. New waterproof gowns were made from old raincoats and polyvinyl chloride piping to survive sodium hypochlorite decontamination. Homemade face shields were made from lamination sheets and unused radiograph films. N95 masks were reused and autoclaved by dry heating. Efforts to improve the supply and maintenance of resuscitation equipment should apply the innovation and experience of frontline providers with real-life, real-time solutions. These solutions may be aided through collaboration with organizations such as Newborn Essential Solutions and Technologies (NEST360°). NEST360° is a global consortium aligned with the World Health Organization and countries in Africa working to “partner with medical, nursing, and engineering schools to sustain a cycle of product development and training, and to inspire the continent’s next generation of innovators to solve future health challenges.”11 

Because of the extensive and complex problems faced in acquiring needed lifesaving equipment, many rely on donations.12,13  However, it is estimated that between 40% and 70% of donated equipment goes unused because it is not functional, it is not appropriate, or staff lack adequate training in its use.1418  Communication is key for procurement of appropriate equipment, improved sustainability, and decreased waste. Training in equipment operation and organized maintenance is equally important. When there is no sustainable alternative to donations, child health providers must advocate for greater accountability in the donation process through institutional, national, or international donation programs such as the Denver-based Project Commission on Urgent Relief and Equipment.19 

For corporate vendors, supply chain barriers include cost, lack of in-country suppliers, and lack of incentive for international corporations to address these issues.20  International organizations working to improve supply chains and overcome barriers include People That Deliver, a program of the World Health Organization, and the United Nations Children’s Fund catalog and warehouse system.2123  Another solution is to shift focus and empower local businesses to manufacture essential supplies. This has been India’s solution and may be well-suited to strong, emerging economies like those in Kenya, Ghana, and Nigeria, where these local businesses could then potentially become local and regional supply leaders.20,24,25  New supply manufacturing should focus on development and production of reusable materials to aid reprocessing for reuse, sustainability, and reduced waste.

The pandemic has shown pediatricians around the world that lives hang in the balance over the gap between equitable, sustainable equipment supply chains and adequate equipment on hand. Whereas neonatal resuscitation equipment and PPE are discussed as case studies for this gap, similar gaps are found in all aspects of pediatric care in LRSs.26  Led by frontline experts, the pediatric community can advocate to close the gap through development and implementation of reprocessing, empowering frontline innovation, demanding transparency and accountability in the donation and sale of equipment, and supporting the startup of local manufacturing in growing economies. Alongside colleagues everywhere, pediatricians must work to assure that lifesaving equipment is available to all children and their health care providers, no matter their country of birth.

The authors thank Cindy Howard, MD, MPHTM, and Tina Slusher, MD, for their insight, comments, and suggestions.

Dr White and Mr Mutai conceptualized the idea of this article and drafted, reviewed, and revised the manuscript; Mr Cheruiyot and Dr Rule conceptualized the idea of this article and critically reviewed and revised the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

FUNDING: No external funding.

     
  • COVID-19

    coronavirus disease 2019

  •  
  • HBB

    Helping Babies Breathe

  •  
  • LRS

    low-resource setting

  •  
  • PPE

    personal protective equipment

  •  
  • SU

    single use

1
UNICEF
.
Neonatal mortality
.
2
World Health Organization
.
Newborns: improving survival and well-being
.
3
Msemo
G
,
Massawe
A
,
Mmbando
D
, et al
.
Newborn mortality and fresh stillbirth rates in Tanzania after helping babies breathe training
.
Pediatrics
.
2013
;
131
(
2
).
4
Niermeyer
S
,
Kamath-Rayne
B
,
Keenan
W
, et al
.
Helping Babies Breathe: Facilitator Flip Chart
, 2nd ed.
Stavanger, Norway
:
Laerdal
;
2016
.
5
PATH
.
Reprocessing guidelines for basic neonatal resuscitation equipment in resource-limited settings
.
6
Centers for Disease Control and Prevention
.
Reuse of single-use medical devices: guideline for disinfection and sterilization in healthcare facilities
.
7
Eslami
P
,
Bucher
S
,
Mungai
R
.
Improper reprocessing of neonatal resuscitation equipment in rural Kenya compromises function: recommendations for more effective implementation of Helping Babies Breathe
.
Resuscitation
.
2015
;
91
:
e5
e6
8
Kuupiel
D
,
Bawontuo
V
,
Mashamba-Thompson
TP
.
Improving the accessibility and efficiency of Point-of-Care diagnostics services in low- and middle-income countries: lean and agile supply chain management
.
Diagnostics (Basel)
.
2017
;
7
(
4
):
58
9
Sunyoto
T
,
Potet
J
,
den Boer
M
, et al
.
Exploring global and country-level barriers to an effective supply of leishmaniasis medicines and diagnostics in eastern Africa: a qualitative study
.
BMJ Open
.
2019
;
9
(
5
):
e029141
10
Fischer
R
,
Morris
DH
,
van Doremalen
N
, et al
.
Effectiveness of N95 respirator decontamination and reuse against SARS-CoV-2 virus
.
Emerg Infect Dis
.
2020
;
26
(
9
):
2253
2255
11
NEST360°
.
Our plan
.
Available at: https://nest360.org/our-plan. Accessed April 20, 2021
12
Bhadelia
N
;
National Public Radio
.
Rage against the busted medical machines
.
13
World Health Organization
.
Medical devices: donation of medical equipment
.
14
Diaconu
K
,
Chen
YF
,
Cummins
C
,
Jimenez Moyao
G
,
Manaseki-Holland
S
,
Lilford
R
.
Methods for medical device and equipment procurement and prioritization within low- and middle-income countries: findings of a systematic literature review
.
Global Health
.
2017
;
13
(
1
):
59
15
Marks
IH
,
Thomas
H
,
Bakhet
M
,
Fitzgerald
E
.
Medical equipment donation in low-resource settings: a review of the literature and guidelines for surgery and anaesthesia in low-income and middle-income countries
.
BMJ Glob Health
.
2019
;
4
(
5
):
e001785
16
McDonald
S
,
Fabbri
A
,
Parker
L
,
Williams
J
,
Bero
L
.
Medical donations are not always free: an assessment of compliance of medicine and medical device donations with World Health Organization guidelines (2009-2017)
.
Int Health
.
2019
;
11
(
5
):
379
402
17
Howie
SRC
,
Hill
SE
,
Peel
D
, et al
.
Beyond good intentions: lessons on equipment donation from an African hospital
.
Bull World Health Organ
.
2008
;
86
(
1
):
52
56
18
Shue
R
.
Partnering in a pandemic: Advancing global access to health during COVID-19
.
2020
.
19
ProjectCURE
.
Crusade against childhood cancers
.
Available at: https://projectcure.org/. Accessed April 20, 2021
20
Kariuki
J
,
Njeru
MK
,
Wamae
W
,
Mackintosh
M
.
Local supply chains for medicines and medical supplies in Kenya: understanding the challenges
.
2015
.
21
People That Deliver
.
Who we are
.
Available at: https://peoplethatdeliver.org/ptd/about-us/who-we-are. Accessed October 1, 2020
22
People That Deliver
.
Healthcare supply chains in developing countries: situational analysis
.
23
UNICEF
.
Warehousing and distribution
.
Available at: https://www.unicef.org/supply/warehousing-and-distribution. Accessed October 1, 2020
24
International Trade Administration
.
India – country commercial guide: healthcare and medical equipment
.
2020
.
25
Medical Device and Diagnostic Industry
.
India’s medical device market is becoming too big to ignore
.
1997
.
26
Slusher
T
,
Bjorklund
A
,
Aanyu
HT
,
Kiragu
A
,
Philip
C
.
The Assessment, Evaluation, and Management of the Critically Ill Child in Resource-Limited International Settings
.
J Pediatr Intensive Care
.
2017
;
6
(
1
):
66
76

Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.