Healthcare workers wear protective masks in this undated photo. (Courtesy of Neighborhood Healthcare)

As the novel coronavirus pandemic escalates in San Diego, local hospitals have put restrictions on highly protective respirator masks to conserve their stockpiles, leading to outcry from healthcare workers who fear the move is shortsighted and puts them at unnecessary risk of contracting the deadly virus.

Three San Diego doctors have even attracted national attention for speaking up about limits on the use of masks and other protective gear. They posted a petition on Tuesday night that urges the federal government to lift the restrictions and distribute more protective equipment for workers on the front lines of the outbreak. It has garnered more than 1 million signatures from across the U.S. in four days.

Why this matters

Around the world, roughly 300,000 people have contracted the novel coronavirus, or COVID-19, including 26,000 in the U.S. and 150 in San Diego.

Recent reports suggest that healthcare workers are more likely to suffer from serious symptoms when they contract the virus. They are risking their health to protect the community from the accelerating pandemic.

Fear among healthcare workers in San Diego and around the country is the result of a slew of quickly changing, ambiguous and contradictory guidelines. San Diego’s hospitals restricted the use of respirator masks following new federal recommendations published on March 10 to address concerns that “the supply chain of respirator (masks) cannot meet demand.”

The guidelines from the Centers for Disease Control and Prevention stated that looser fitting, less protective surgical masks are an “acceptable alternative” for interacting with patients who have COVID-19, the disease caused by coronavirus, when respirator masks, including what are called N95 masks, are in short supply. In these cases, the N95 masks, which filter out 95 percent of particles in the air, can be reserved for “aerosolizing” procedures such as intubation and bronchoscopies that can cause the virus to become airborne and increase the chance of infecting others.

However, the updated guidelines are only supposed to be in place while supplies of the more protective masks are low, suggesting that surgical masks may not be sufficient on their own to prevent medical staff from contracting the virus.

Plus, the California government still recommends that healthcare workers wear N95 masks when interacting with COVID-19 patients. The website for the state’s Division of Occupational Safety and Health says that surgical masks “cannot be relied upon for novel pathogens” and “must not be used instead of an approved respirator such as an N95 mask.”

RELATED: The struggle in San Diego to get COVID-19 safety gear for healthcare clinics

San Diego County leaders and hospital officials have insisted there is no shortage of masks in the region, yet they have tightened the rules for using masks anyway. Healthcare workers told inewsource that hospital managers should be providing every respirator mask they can to current staff, rather than stockpiling them for the future and risk more doctors and nurses falling ill in the meantime.

On Thursday night, a group of nurses stood outside the UC San Diego Medical Center in Hillcrest between shifts, relaying their frustration with the university for limiting access to protective gear. The nurses, who are all members of California Nurses Association, described the mask restrictions as irresponsible, outrageous and appalling.

Shannon Cotton, a registered nurse in the Hillcrest ICU, speaks at a news conference outside of UCSD Medical Center, March 19, 2020. (Zoë Meyers/inewsource)

“As nurses, we’re on the front line, and what we’re seeing is UCSD stockpiling and rationing masks,” said Shannon Cotton, a registered nurse in the Hillcrest ICU. “They keep on telling us that we’re prepared, we’re ready for the surge, but if that’s true, then why are they rationing the masks?

“Why don’t they give it to us now to all nurses, to all staff so that we can slow the spread of the virus and maybe we won’t have to worry about a surge later on? We can stop it now.”

Close watch

The petition by the three UCSD doctors was posted days after the new CDC mask rules went into effect.

“We hoped to bring attention to the national shortage of personal protective equipment (PPE) for healthcare workers on the front lines caring for patients with COVID-19,” the co-authors wrote in an email to inewsource, speaking on their own behalf and not on behalf of UCSD.

Drs. Milla Kviatkovsky, Constance Chace and Supraja Thota said in the email that the restrictions are a national problem that go well beyond their hospital and city. Their petition asks the U.S. government to deploy its stockpile of protective equipment and seek alternative sources to manufacture and import necessary gear.

“We have communicated with healthcare workers across the country, and it is clear that supplies are already low or exhausted, and we are only at the tip of the iceberg,” the email said.

UCSD anticipates releasing details of its updated policy on the use of N95 masks Monday, but an intake nurse said that her hospital’s masks are kept under close watch. Staff have to call a command center and explain the reason they need the masks, and if approved, they are given directly to the healthcare workers requesting them.

About this report

As the coronavirus spreads across the U.S. and in San Diego County, so does uncertainty. To provide you with accurate in-depth reporting on the pandemic, KPBS and inewsource are collaborating in their news coverage.

The nurse, who did not want her name published because she’s worried about the consequences at work of speaking up, treats people on a hospital floor with COVID-19 patients.

“For me and my co-workers, it’s been definitely scary at times,” she said, and later adding, “if the staff is getting sick, who is going to take care of these patients?”

Elizabeth Jones, another nurse at UCSD and member of the nurses union, said hospital staff were informed in an email they will be disciplined if they wear any kind of protective mask outside of patient rooms. They were also told to rewear respirator masks and store them in biohazard bags in between uses, she said, even though they’re only supposed to be worn once to avoid contamination.

“That’s so unsanitary and completely breaks infection control,” Jones said in a Saturday morning interview after her graveyard shift at the hospital.

“We want to be able to protect ourselves by wearing masks and goggles when we’re in the unit, because we are talking to patients who are in hallways and walking around,” Jones said. “We have co-workers that may have been exposed and aren’t showing symptoms yet. So we want to be able to be protected as best as possible.”

In a statement, UCSD spokeswoman Jackie Carr said there is no supply shortage at the university’s hospitals, but if N95 masks were used by all hospital staff there could be in the future.

“Universal masking would lead to an immediate reduction of mask stock before the peak of the COVID-19 epidemic,” Carr said. “Instead, we need to be thoughtful about the use of each and every mask to care for everyone.”

Carr said the hospitals are following guidelines from the CDC and World Health Organization, which “represent the latest, empirical analyses by national and international authorities on the most appropriate standards of care.”

Some data supports the CDC’s claims. Evidence suggests the virus is most commonly transmitted through coughing and sneezing, which can likely be prevented with a simple surgical mask. Also, a 2019 study found that healthcare workers wearing N95 masks were just as likely to catch the flu as staff wearing surgical masks, meaning the more protective equipment may not be necessary.

Additional N95 masks are received at Family Health Centers’ warehouse in San Diego, March 20, 2020. (Zoë Meyers/inewsource)

But nurses and doctors who spoke with inewsource have doubted that the CDC’s guidelines are based on clear scientific evidence. While some preliminary studies have found no evidence that the novel coronavirus can be transmitted through the air, emerging research suggests otherwise.

Data from a Harvard University study on Chinese healthcare workers treating COVID-19 patients found workers were more likely to contract the virus than the general public. Once the workers started wearing more protective gear — including suits, goggles, N95 masks and gloves — almost none of them contracted the virus.

The American Nurses Association, which represents 4 million nurses in the U.S., published a news release shortly after the CDC’s guidelines changed, sharing its concerns that the new policy was solely based on supply chain issues and not scientific evidence.

Leaders of other nursing unions have been more understanding of the change. Denise Duncan, president of United Nurses Associations of California, published a Facebook post Thursday in response to concerns from members.

“As for the workplace, nurses are asking for N95 masks even when they may not be completely warranted,” wrote Duncan, whose union represents San Diego nurses working at Sharp Memorial Hospital and Kaiser Permanente. Nurses, she said, “have been seen wearing them at the market and supplies are being stolen out of this nation’s hospitals.”

“We know supplies are very, very limited. We are working diligently to … get supplies for our members as rapidly as they become available.”

Jay O’Brien, president of Sharp’s chapter of the union, said he has spent many hours reading policies and studies about the virus and is not concerned about the mask restrictions.

O’Brien helps educate the 5,000 nurses working in Sharp Healthcare about the latest COVID-19 news and works with management to ensure staff are receiving proper protections. Although N95 masks would be ideal, he said, the latest information coming out of COVID-19 hotspots in China and Italy suggest that in most cases surgical masks suffice.

“People are nervous and they’re cautious,” O’Brien said. “What I’ve been running into is there’s a lot of questions. And what my observation has been, that once people fully understand the precautions and the reasons and some of the details of it, they get it and they’re actually volunteering to work with these patients.”

‘Getting what they need’

San Diego’s healthcare centers have been increasing their requests for extra medical supplies from the county stockpile since COVID-19 cases were first reported in the region weeks ago, but county officials say they’ve been able to keep up with demand.

At a Friday news conference, Public Health Officer Dr. Wilma Wooten said the county’s medical operations center received and fulfilled more than 150 requests for protective gear in the past week, but she didn’t specify how many of those requests were for masks.

Public Health Officer Dr. Wilma Wooten speaks at a San Diego County news conference with Board of Supervisors Chairman Greg Cox, March 19, 2020. (Zoë Meyers/inewsource)

Wooten said new restrictions have reduced the burn rate of medical gear significantly and resulted in a hefty stockpile of 700,000 respirator masks.

“I can tell you (with) 100% assurance that with N95 masks there is no supply issue there,” Wooten said.

She added that some items are in short supply — gowns, gloves and goggles — and the county is aiming for a stockpile that can last four to six weeks.

Most of San Diego’s major hospitals wouldn’t provide the exact number of masks they have available, instead offering generic statements explaining their supplies are currently sufficient.

At Kaiser Permanente, hospital staff are “managing our inventory of protective equipment carefully,” and “monitoring supplies and distribution in all facilities to ensure our staff are trained and have access to the protective equipment or garments they need.”

Scripps Health said on Thursday it had a two-weeks’ supply of N95 masks and was expecting another delivery from the county later that day. The hospital is “constantly looking for vendors with supply,” including the local government and international sources.

As for the San Diego VA, which serves the region’s more than quarter million veterans, its hospital “is equipped with essential items and supplies,” a spokeswoman said in an email.

But tight limits on mask use remain. An email to VA medical staff on Feb. 28 obtained by inewsource encouraged healthcare workers to reuse N95 masks and store them in “zip lock bags” in between uses, even though the standard policy is to discard them after they are worn.

Rob Sills, who directs the county’s medical operations center, said at a Friday news conference that healthcare facilities requesting protective gear are receiving it the same day. He added that the pipeline of emergency supplies from the state “is starting to open up” and the county is in the process of receiving more equipment at its warehouse.

“I don’t think a day has gone by since the last week of November that I have not spoken to an emergency manager from one of our healthcare systems,” Sills said, “and they are getting what they need.”

However, the situation is more dire at San Diego’s health clinics that provide medical care to uninsured and low-income patients. These clinics are the primary resource for many underrepresented groups in the county, and some have been testing and treating patients who show symptoms of COVID-19.

Warehouse supervisor Andres Castro unloads a delivery of masks from the county at Family Health Centers’ warehouse in San Diego, March 20, 2020. (Zoë Meyers/inewsource)

A representative from Family Health Centers of San Diego, which serves more than 210,000 patients a year, told reporters that the nonprofit had asked the county for equipment that it couldn’t order from its vendors, including surgical masks, N95 masks, gloves, gowns and sanitizer. The county did provide 10,000 N95 masks, but not the other items.

The masks were past their manufacturer shelf life but federal guidelines have said they can be used in times of a shortage.

As of March 17, the nonprofit had three boxes of surgical masks and about 15 N95 masks remaining, said CEO Fran Butler-Cohen. If the clinics run out of masks, they won’t be able to see patients with COVID-19 symptoms.

“If I can’t get a supply for that, I cannot allow physicians to see people that we believe may have COVID-19, may have the coronavirus,” Butler-Cohen said. “I can’t allow them to see those patients and put them at risk.”

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Jill Castellano is an investigative data coordinator for inewsource. When she's not deep in a spreadsheet or holed up reporting and writing her next story, she's probably hiking, running or rock climbing. She also loves playing board games and discussing the latest chapters with her book club. Jill...

Tarryn Mento is the health reporter for KPBS. She has reported from three countries and in two languages. Her work has been published by The Washington Post, the Center for Public Integrity’s iWatch News, and El Nuevo Herald. Prior to serving as KPBS' health reporter, Tarryn was the multimedia producer...