Coronavirus Disease 2019: Health Emergency Supply Note - UNICEF Supply Division February 2020
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Coronavirus Disease 2019: Health Emergency Supply Note February 2020 1. Summary The formal name for the 2019 novel coronavirus (2019-nCoV) is now the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), and the name for the disease caused by the virus is coronavirus disease 2019 (COVID-19).1 In response to the outbreak of SARS-CoV-2 in Wuhan, Hubei Province, China,2,3 UNICEF is providing a list of essential supplies for the prevention and the symptomatic treatment of mild cases, and emergency response. This list has been adapted from UNICEF’s supply lists for other coronaviruses, notably severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS). Based on the latest available information as of the release date of this note, the list includes supplies for infection prevention and control (IPC), personal protective equipment (PPE) for airborne and droplet precautions, medical equipment, and medical clothing for standard precautions to extend biological protection barriers, as well as waste management. No antiviral treatment or vaccine currently exists for COVID 2019. Supportive care and transmission prevention are currently the most effective interventions. UNICEF also provides information on the current market for supplies and actions by UNICEF to address prevailing supply constraints. 2. Background Coronavirus disease 2019 is a respiratory disease caused by the novel coronavirus, SARS-CoV-2. Previous nCoVs include SARS and MERS. This new COVID-19 was first identified in China in December 2019 and is currently spreading in China and other countries in the region and beyond.4 Currently, the outbreak has affected more than 28 countries across all regions, and as of 14 February 2020, has reached just under 65,000 confirmed cases, of which 16 per cent have been considered severe and of which over 1,300 cases have resulted in death, mostly among adults aged between 25-89 years of age.5 There is currently limited information on COVID-19 as it is an outbreak of a new disease with emergency services in full response mode. The latest information on COVID-19 outbreak is available here: https://www.who.int/emergencies/diseases/novel- coronavirus-2019. Current modes of transmission are unknown. However, available information suggests zoonotic transmission,6 and cases of human to human transmission is confirmed. Symptoms of infection include fever, cough, fatigue, sputum (saliva and mucus), sore throat, chest discomfort, shortness of breath, and headaches. The World Health Organization (WHO) identifies an estimated incubation period of up to fourteen days with a mean average of 5.5 to 6 days.7 as well as body aches to mild respiratory symptoms. Most develop pneumonia and approximately ten to twenty per cent develop diarrhoea. No curative treatment or vaccine exists for COVID-19. Infection prevention and control measures are critical to prevent all respiratory diseases, especially in health‐care facilities. Transmission prevention recommendations include guidance for contact, airborne, and whenever applicable, droplet precautions, which include a higher level of PPE for frontline workers, including eye protection, and the expanded use of respirators. WHO and the United States Centers for Disease Control and Prevention (CDC) provide detailed respective information on the different prevention and control measures to be followed: • WHO Infection prevention and control during health care when COVID-19 infection is suspected: https://www.who.int/publications-detail/infection-prevention-and-control-during-health-care-when-novel-coronavirus- (ncov)-infection-is-suspected-20200125 • WHO sections on COVID-19 technical guidance and infection prevention and control for: o Infection prevention and control during health care when COVID-19 infection is suspected; 1 University of Minnesota, Deaths From Newly Named Coronavirus Disease Top 1,000, Center for Infectious Disease Research and Policy (CIDRAP), Minneapolis, 11 February 2020. 2 World Health Organization, Novel Coronavirus (2019-nCoV), WHO, Geneva, 2020. 3 Centers for Disease Control and Prevention, 2019 Novel Coronavirus, Wuhan, China, CDC, Atlanta, 2020. 4 World Health Organization, Novel Coronavirus China, WHO, Geneva, January 2020. 5 John Hopkins University, Coronavirus 2019-nCoV Global Cases, Johns Hopkins Center for Systems Science and Engineering, Baltimore, 10 February 2020. 6 Note: Zoonotic infections are diseases that spread between animals and humans. Center for Disease Control and Prevention, Zoonotic Diseases, CDC, Atlanta, July 2017. 7 World Health Organization, Public Health Emergencies Bulletin: Novel Coronavirus (nCoV) Update -1, WHO, Geneva, 21 January 2020. 1
o Home care for patients with suspected COVID-19 infection presenting with mild symptoms and management of contacts; o Question and answers on infection prevention and control for health care workers caring for patients with suspected or confirmed COVID-19. https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/infection-prevention-and- control • WHO guidance for the public on basic protective measures against COVID-19: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public • CDC interim guidance on implementing homecare for people that do not require hospitalization for COVID-19: https://www.cdc.gov/coronavirus/2019-ncov/downloads/guidance-home-care.pdf • CDC interim infection prevention and control recommendations for patients with confirmed COVID-19 or persons under investigation for nCoV in healthcare settings: https://www.cdc.gov/coronavirus/2019-nCoV/hcp/infection-control.html 3. Supply 3.1. Global Market Outlook Following the outbreak of COVID-19, UNICEF and partners have registered an unprecedented increase in demand from China and other countries seeking to secure IPC and PPE supplies, including for critical items such as surgical face masks, N95 respirators, gowns, coveralls, gloves, and hand sanitisers. The surge in demand is currently applying pressure on global manufacturer production capacities and supply availability, with markets now facing severe disruptions, while at the same time applying significantly increased pressure on pricing. China is the largest producer of IPC and PPE finished products, as well as of many of the raw materials needed to manufacture PPE. It produces an estimated 50 per cent of surgical masks globally, roughly estimated to be 20 million masks a day.8 Face masks (surgical and N95) are currently facing the largest supply constraints, in addition to coveralls and gowns, with market demand estimates having more than doubled. Many stocks normally held by manufacturers, wholesalers, and distributors have been depleted, and has resulted in an increasing backlog of orders. Current market assessments estimate possible delays in lead-times for delivery having increased by up to four to six months. WHO has warned that the prevailing market situation is also being exacerbated by the widespread inappropriate use of IPC and PPE outside of patient care.9 Whereas WHO advises that the rational, correct, and consistent use of PPE can help to reduce the spread of pathogens, the effective use of PPEs strongly depends on adequate and regular supplies, in addition to adequate staff training, appropriate hand hygiene, and appropriate human behaviour.10 Hubei Province, the epicentre of the COVID-19 outbreak, has an estimated 500,000 medical staff alone.11 In response to the emergency, the Chinese government has temporarily imposed export restrictions on PPE to prioritize supply to in-country healthcare facilities. In addition, some other countries that produce PPE are also restricting exports to ensure that supplies are available for domestic needs. This has increasingly limited the availability of, and access to, these supplies for other countries. Under the COVID-19’s prevailing circumstances, front-line health workers require most of the limited stock of PPE supplies. As such, WHO recommends: • Any stocks are to be issued as a priority to health workers, and secondly to patients that are sick and those caring for anyone who is ill. • To discourage countries from stockpiling any PPE where transmission is considered low. 8 BBC, Coronavirus: Does China Have Enough Face Masks to Meet Its Needs?, BBC, London, 6 February 2020. 9 World Health Organization, WHO Emergencies Press Conference on Novel Coronavirus Briefing, WHO, Geneva, 7 February 2020. 10 World Health Organization, Infection Prevention and Control During Health Care When Novel Coronavirus (nCoV) Infection is Suspected, Interim Guidance, WHO, Geneva, 25 January 2020, p. 2. 11 Ibid. 2
• Calling on countries and companies to work with WHO and partners to ensure the fair and rational use of any supplies as well as to rebalance the market. The current constrained market situation is inevitably also affecting the availability of some IPC and PPE through UNICEF. While UNICEF is undertaking all efforts to expand and diversify its supply base, and to identify alternative sources of quality- assured products, as well as to encourage manufacturers to increase production capacity, not all requests routed to UNICEF may be met through international sources in the near-term. Where feasible, UNICEF advises countries to source as many of the supplies as possible locally or regionally, while all attempts are made to secure additional supplies internationally and to prioritize their allocations. WHO has issued detailed guidelines and advice for the public on COVID-19, which is accessible here: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public Summary guidance vignettes are available below: 3.2. UNICEF Actions To respond to the increased demand from countries seeking supplies through UNICEF, UNICEF has since the outbreak: • Undertaken a mapping of all PPE suppliers as well as a demand forecast modelling exercise, calculating country requirements for surgical masks, gowns, and coveralls to formulate and communicate requests to suppliers to leverage and influence an increase in production capacity. • Instigated a six-fold increase in the level of stocks it can hold on its emergency supply list (ESL), as well an increase in the value threshold of its ESL. The ESL is a non-exhaustive list of critical supplies UNICEF consolidates for use in emergencies. • Issued recommendations to country offices to source locally as a matter of priority, not only to address supply challenges, but also logistic challenges to deliver PPE as well as disinfectants. • Has been working closely with the Pandemic Supply Chain Network (PSCN) that aims to support and operationalise a multi-stakeholder mechanism and platform to coordinate visibility on the production, availability, and allocation of strategically critical products and services essential in managing large disease outbreaks of international concern.12 3.3. Supply Lists UNICEF has adapted its list of SARS consumables and supplies that are available for procurement and use in the event of an acute respiratory infection outbreak to be suitable for the current knowledge on COVID-19 (Table 1, next page). This version of the note will be updated as more information on the COVID-19 becomes available. 12The Pandemic Supply Chain Network (PSCN) is a global network of both public and private sector corporations, organizations, and service providers, including UNICEF, involved in emergency supply chain operations. Formed in 2014 following the outbreak of Ebola virus disease in West Africa, they seek to ensure the timely delivery of critical health supplies to the people who need it most. World Economic Forum, Pandemic Supply Chain Network (PSCN), WEF, Geneva, 2020. 3
Table 1 UNICEF COVID-19 HEPI Supply List Area Item Description Material Number Unit Oxygen concentrator set S0002047 Set Resuscitation kit, basic S9908400 Each Thermometer, clinical, digital, no lithium S0481056 Each Case Management Thermometer, clinical, IR, handheld set S0481054 Set Paracetamol 100mg disp. tabs/PAC-100 S1555979 Pack Paracetamol 500mg tabs/PAC-100 S1555964 Pack Faceshield, fog-resistant, full face, disp. S0305116 Each Goggles, protective, indirect-side ventilation S0305144 Each Mask, high-fil., FFP2/N-95, no-valve, none sterile S0305109 Each Mask, high-fil., FFP2/N-95, valve, none sterile/BOX-10 S6780349 Each Mask, medical, type I, dis./PAC-50 S0305146 Each Mask, surgical, type IIR, tie strap, disp./PAC50 S0305135 Pack Cap, surgical, bouffant, non-woven S0305078 Each Gown, surgical, non-sterile, non-woven, disp., L S0305138 Each Gown, surgical, non-sterile, non-woven, disp., XL S0305140 Each Apron, protect, plastic, disp./PAC-100 S0305131 Pack Apron, protection, plastic, reusable S0305132 Each Coverall, protection, Cat III, type 6b, L S0305117 Each Coverall, protection, Cat III, type 6b, M S0305126 Each Coverall, protection, Cat III, type 6b, XL S0305127 Each Prevention Gloves, heavy-duty, rubber/nitrile, pair, L S0327552 Pair IPC and PPE Gloves, heavy-duty, rubber/nitrile, pair, M S0327551 Pair Gloves, heavy-duty, rubber/nitrile, pair, S S0327550 Pair Gloves, w/o powder, nitrile, L, disp./BOX-100 S0969026 Box Gloves, w/o powder, nitrile, M, disp./BOX-100 S0969025 Box Boot cover, anti-skid, elasticated, pair S0305129 Pair Boots, rubber/PVC, reusable, pair, size 42 S0305061 Pair Boots, rubber/PVC, reusable, pair, size 43 S0305062 Pair Boots, rubber/PVC, reusable, pair, size 44 S0305063 Pair Body bag, infection control, adult S0990002 Each Body bag, infection control, child S0990003 Each Bag, biohazard, red, 100l/BOX-100 S0969007 Box Calcium hypochlorite 65-70%** S0000569 Pack NaDCC, chlorine granules 56%, ½kg* S5006055 Each Hand sanitizer, alcohol >60%, 75-100ml* S0006558 Each Container, used sharps, leakproof, 5L S5006287 Each Vaccine No vaccine is currently available Diagnostics No diagnostic test is currently available Should interventions need operational or programmatic equipment for use in temporary structures during an outbreak, items should include the following: Trousers, surgical, woven, size L S0305081 Each Trousers, surgical, woven, size M S0305080 Each Trousers, surgical, woven, size XL S0305082 Each Tunic, surgical, woven, size L S0305084 Each Tunic, surgical, woven, size M S0305083 Each Tunic, surgical, woven, size XL S0305085 Each Bed screen, hospital, on castors S0101015 Each Operational and Blanket, fleece, medium, thermal, 150x200cm S5086015 Each Programmatic Supplies Cot, medical, IV-pole, basic S0120021 Each Stretcher, foldable S0180000 Each Tarpaulin, plastic FR sheet, 4x5m S5086014 Each Tent, light weight, rectangular, 42m² S5088015 Each Tent, light weight, rectangular, 72m² S5088020 Each Warning fence, plastic/ROLL-1mx50m S8913995 Each Generator set, diesel, air cooled, 5kVA** S0005406 Each Source: UNICEF Note *: Classed as dangerous goods. 4
4. Other Key Considerations In addition to the items listed in Table 1 that address disease available supplies, Table 2 includes several additional useful considerations, such as the interagency emergency health kit (IEHK), and documents related to IPC and PPE. The IEHK is a standardized kit of essential medicines, supplies, and equipment designed to meet the basic health care needs of 10.000 persons for three months in large-scale emergencies.13 The kit is designed for use in emergency settings, where medical supplies are disrupted, and fills the needs until the medical supply chain is restored. Although the kit is not specifically designed for SARS-CoV-2 outbreak response, it can be used for palliative care to address symptomatic relief where there is a disruption to basic medical supplies. The IEHK complete kit includes one basic unit and six supplementary units, ordered together or individually (see Section 5). Table 2 UNICEF Other Key Considerations – Continued Overleaf Category Description IEHK – Basic Unit: Material Number: S9901024 The basic unit is one part of the "IEHK complete kit". It contains essential medicines and medical devices (consumables and equipment) for a population of 1,000 persons for a period of three (3) months during emergency situations. The basic unit contains essential medicines (none of which can be injected) and medical devices (consumables and equipment essentially for dressing purposes). It can be used by healthcare workers with limited training. IEHK – Basic Unit Malaria: Material Number: S9901025 The basic unit malaria contains the essential medicines and medical devices (renewables and equipment) for a population of 10,000 persons for a period of three (3) months for use by health workers with oral antimalarial medicines and malaria rapid diagnostic tests (mRDTs). Whereas the basic module above is supplied as part of a whole kit, countries can remove this component on request (as an opt out), as malaria may not be an issue in those countries. IEHK – Supplementary Unit 1 - Medicines: Material Number: S9901026 The supplementary unit 1 - medicines contains essential medicines for a population of 10.000 persons for a period of three (3) months. The selection and quantification of the medicines included are based on recommendations for treatments for target diseases. Reference is made to "MSF Essential Drugs - Practical Guidelines" and "MSF Clinical, Diagnostic and Treatment guidelines". This kit must only be used by physicians and other professional health worker. IEHK – Supplementary Unit 1a - Medicines: Material Number: S9901027 The supplementary unit 1a - medicines contains medicines that normally need import authorizations (narcotic / psychotropic substances). Since this kit is usually urgently required and needs to be shipped within 24 hours, it Interagency Emergency does not allow time to apply for import and export authorizations. Therefore, until further notice, UNICEF Supply Health Kit Division will not require import authorizations for this kit. However, country offices ordering or receiving this kit are advised to investigate if their national authorities require an import authorization. For these shipments, UNICEF Supply Division will complete the "Notation Form for Emergency Supplies of Controlled Substances" and forward it to the DMA (Danish Medicines Agency). Please refer to Supply Directive CF/SD/2008/002 Rev 01 - ordering of narcotic and/or psychotropic pharmaceutical products. This kit is therefore only supplied via air shipment. This kit must only be used by physicians and other professional health workers. IEHK – Supplementary Unit 1b - Malaria: Material Number: S9901028 The supplementary unit 1b - malaria contains injectable anti-malarial medicines Artesunate powder injection 60mg vial. The kit must only be used by physicians and other professional health workers. Whereas the basic module above is supplied as a part of a whole kit, countries can remove this component on request (as an opt out), as malaria may not be an issue in those countries. IEHK – Supplementary Unit 1c – Cold Chain Medicines: Material Number: S9901022 The supplementary unit 1c - cold chain medicines contain medicines that must be transported and stored at 2 to 8ºC (350F to 460F) in a cold chain and to be transported by airfreight. IEHK – Supplementary Unit 2 - Equipment: Material Number: S9901029 The supplementary unit 2 - equipment contains essential medical equipment (e.g. basic diagnostic and sterilisation equipment, medical utensils, and minor surgical instruments sets). It also includes items to allow for the provision of clean water. This kit must only be used by physicians and other professional health workers. IEHK – Supplementary Unit 3 - Renewable: Material Number: S9901030 The supplementary unit 3 - renewable contains essential consumable medical devices. Most of the items are single use and sterile. This kit must only be used by physicians and other professional health workers. 13 UNICEF Interagency Emergency Health Kit – Information Note, UNICEF, Copenhagen, 2020. 5
IEHK – PEP Kit: Material Number: S9901023 Interagency Emergency The PEP kit contains medicines for emergency post-exposure prophylaxis of HIV infection and other sexually Health Kit cont. transmitted infections (STIs). It also contains emergency contraceptives and pregnancy tests. IPC – WHO and CDC Guidance for Acute Respiratory Diseases It is critical that health-care workers use appropriate infection control precautions when providing care to minimize the possibility of transmission of infection to themselves, other health-care workers, patients, and visitors. WHO provides guidance on infection, prevention and control for epidemic and pandemic-prone acute respiratory diseases, accessible here:14 https://www.who.int/emergencies/diseases/novel-coronavirus-2019 and here: https://www.who.int/publications-detail/infection-prevention-and-control-during-health-care-when-novel-coronavirus- (ncov)-infection-is-suspected and CDC here: https://www.cdc.gov/coronavirus/2019-ncov/index.html IPC – CDC Guidance for Isolation Precautions CDC provides guidelines for isolation precautions to prevent the transmission of infectious agents in healthcare settings, and is accessible here: 15 https://www.cdc.gov/infectioncontrol/pdf/guidelines/isolation-guidelines-H.pdf PPE – WHO Doffing and Donning Instructions Frontline workers must don adequate and effective PPE to protect from infection in addition to the firm application of contact and standard universal precautions to provide a maximum safety level against infective agents; and for use in accordance with instructions. WHO provides detailed instructions for health-care professionals on “How to Put on and How to Remove Personal Protective Equipment” before and after visiting treatment centres, or isolation units, accessible here:16 http://www.who.int/csr/resources/publications/ebola/ppe-steps/en/ Prevention PPE – CDC Doffing and Donning Instructions IPC and PPE CDC provides guidance for use by staff on how to use PPEs to protect themselves from exposure to microbiological hazards in the healthcare settings and includes the sequence to doff and done PPEs to reinforce safe practices intended to limit the spread of contamination, accessible here:17 https://www.cdc.gov/hai/pdfs/ppe/PPE-Sequence.pdf PPE – UNICEF Product Technical Specifications UNICEF will soon provide a detailed update and list of airborne and droplets PPE technical specifications for use in high- and low-risk settings. The equipment extends biological protection barriers to prevent percutaneous and mucocutaneous exposure, and it includes barriers for full body protection, as well as the head, nose, mouth, eyes, hands and feet. In selecting the right PPE specifications for frontline workers, the degree of contact with infectious material, and the potential for infected fluid penetration should be considered. WHO Waste Disposal Guidance WHO provides comprehensive guidance on the safe, efficient, and environmentally sound methods for the handling and disposal of health-care wastes including infectious waste and in emergencies, accessible here: 18 http://www.who.int/water_sanitation_health/publications/safe-management-of-wastes-from-healthcare-activities/en/ As well as Overview of technologies for the treatment of infectious and sharp waste from health care facilities: https://www.who.int/water_sanitation_health/publications/technologies-for-the-treatment-of-infectious-and-sharp- waste/en/ Source: The CDC, WHO, and UNICEF 5. How to Procure Emergency Supplies through UNICEF 5.1. UNICEF Country Office Orders for Health Emergency Supplies In the event of an emergency, UNICEF country offices can access the UNICEF health emergency supply list above by raising an emergency UNICEF sales order (SO) through UNICEF's internal virtual integrated system of information (VISION), which manages all transactions. UNICEF country offices raise and authorize SOs in VISION with an “Order Reason” stating emergency. UNICEF country offices can identify commodities online via UNICEF’s Supply Catalogue, or UNICEF’s intranet Emergency Supply List (ESL). UNICEF Supply Division’s (SD) Emergency Coordinator (email: danemergency@unicef.org) receives the order in VISION. The Emergency Coordinator reviews and considers the order for approval. UNICEF asks country offices to provide information on the planned use of the supplies and on their integration into the national preparedness or response plans. Given the current shortages in some critical supplies, UNICEF needs to review the requests to prioritize supply allocations. 14 World Health Organization, Epidemic- and Pandemic-prone Acute Respiratory Disease Infection Prevention and Control, WHO, Geneva, 2007. 15 The Centers for Disease Control and Prevention, 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, CDC, Atlanta, February 2017. 16 World Health Organization, How to Put On and How to Remove Personal Protective Equipment, WHO, Geneva, January 2015. 17 The Centers for Disease Control and Prevention, Sequence for Putting On Personal Protective Equipment, CDC, Atlanta, October 2016. 18 World Health Organization, Safe Management of Wastes from Health-care Activities, 2nd ed., WHO, Geneva, 2014. 6
Once approved in VISION, the Emergency Coordinator directs the different materials to the relevant UNICEF SD procurement centres. Procurement centres initiate procurement and raise purchase orders (PO) for the requested supplies from UNICEF SD’s warehouse in Copenhagen, or directly from suppliers located across the globe. UNICEF staff can access detailed information on how to order for emergencies via the intranet ICON pages on: • Chapter 10: Emergencies Section 03: Emergency response (UNICEF Staff only) • Logistics and Supply Emergency Calculator (see Health Emergency Situations) The Logistics and Supply Emergency Calculator (LASEC) application is an online tool whose goal is to support and facilitate UNICEF country offices in the decisional process related to the procurement of first wave of emergency items required to respond to emergency situations. It provides an estimate on ESL items, freight costs, weight and volume, stock levels, charter options and a summary view taking into account all of the above. 5.2. Government, External Partners and Other UN Agency Orders for Health Emergency Supplies Partners (governments, NGOs, other UN agencies) can access COVID-19 health emergency supplies using their own financing through UNICEF’s Procurement Services (PS). In emergencies PS can be used for preparedness and after a first- wave response. However, for a first-wave response, UNICEF advises partners to use UNICEF’s emergency procurement channels, which is more appropriate (see Section 5.1). As the supply availability of some critical items needed in the COVID- 19 response is severely constrained, they may be subject to significant delays in delivery. Any requests for these supplies, including their priority allocation, will similarly be coordinated via UNICEF SD’s Emergency Coordinator. Any responses to requests will include communication on instructions and contingencies via cost estimates to partners. UNICEF encourages partners in country to first consult supply staff in UNICEF country offices accordingly. Partners can also access detailed information via: • How to use UNICEF Procurement Services: https://www.unicef.org/supply/index_purchasing.html • The list of UNICEF country offices and their contact details can be found here: https://www.unicef.org/about/structure/index_field.html For further questions or additional information, please contact: Djani Zadi Nagwa Hasanin Aadrian Sullivan Emergency Coordination Unit Senior Advisor (Health) Information Management UNICEF Supply Division UNICEF Supply Division UNICEF Supply Division +45 45 33 55 00 +45 45 33 58 38 +45 45 33 57 68 danemergency@UNICEF.org nhasanin@UNICEF.org asullivan@UNICEF.org Other UNICEF information notes are found at https://www.unicef.org/supply/index_102649.html 7
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