Technical Appendix
The estimated number of non-healthcare essential workers who tested positive for COVID-19 was estimated using industry-specific data on COVID-19 cases in Washington through May 27, 2020, as these were the most comprehensive available data with information on COVID-19 patient industry of employment. In Washington, the total number of positive cases in other industries that most closely match the list of industries to which California has already provided masks during COVID-19[38] (Accommodation and Food Services, Agriculture, Forestry, Fishing and Hunting, Construction, Transportation and Warehousing, Public Administration, Administrative and Support and Waste Management and Remediation Services, Educational Services, and Utilities) is equivalent to 93% of the positive cases in the Health Care and Social Assistance Industry.[39] To estimate the number of California non-healthcare essential workers who tested positive for COVID-19, we applied 93% to the number of healthcare worker cases reported by the California Department of Public Health.[40]
We examined healthcare and essential worker cases beyond a 90-day period because if the state and healthcare providers already had a 90-day stockpile in place when COVID-19 began, the benefit of having adequate PPE would have extended beyond 90 days—as soon as the 90-day stockpile began to be used, the state and healthcare providers could have focused on acquiring PPE to use once the stockpile is depleted, rather than needing to fill the immediate needs. Additionally, even when examining healthcare and essential worker cases beyond 90 days, our estimates of the number of infected workers are likely to be low because of the COVID-19 testing limitations, which were particularly severe early in the pandemic.
We analyzed California nursing home data from the U.S. Center for Medicare and Medicaid Services to estimate the percentage of nursing home staff cases occurring in the context of a cluster of COVID-19 cases. We defined a cluster as a total of five or more confirmed or suspected staff and patient cases in a nursing home during any given week. For each nursing home experiencing a cluster of cases, we summed all confirmed staff cases reported that week and subtracted one case, to make the conservative assumption that the other staff cases originated from an index staff case that was community-acquired. This is a conservative assumption, as many cases likely originated from a patient admitted with COVID-19, a visitor, or from spread of the virus in the facility in prior weeks. Using these assumptions, we estimated that during the five weeks ending May 31 through June 28, 2020, an average of 73% of all confirmed staff cases in Californian nursing homes occurred in the context of a cluster of cases.[41] We estimated that the 15,800 potentially avoidable cases among healthcare and other essential workers and their household members were associated with approximately 300 hospitalizations at an estimated cost of $7.9 million. The estimated number of hospitalizations was based on hospitalization rates by age group published by the UC Berkeley Petris Center.[42] The 13,500 worker cases were distributed by age group based on the age distribution of COVID-19 positive workers in Washington state who provided employment information,[43] and the age distribution for the 2,300 household cases was estimated using a study of secondary COVID-19 attacks within households.[44] The cost of these hospitalizations was estimated based on costs per COVID-19 hospitalization by payer type from Avalere,[45] weighted based on the coverage type distribution of all California children and California workers ages 20-64[46] and assuming all cases ages 65+ were covered by Medicare.
Endnotes
[*] No external funding was received for this research. We thank Economic Development Department staff for providing unemployment insurance claims data. All errors are our own.
[1] Lydia DePillis and Lisa Song, “In Desperation, New York State Pays Up to 15 Times the Normal Prices for Medical Equipment,” ProPublica, April 2, 2020, https://www.propublica.org/article/in-desperation-new-york-state-pays-up-to-15-times-the-normal-price-for-medical-equipment.
[2] Mark Maremont, Austen Hufford, and Tom McGinty, “U.S. Pays High Prices for Masks From Unproven Vendors in Coronavirus Fight,” Wall Street Journal, April 18, 2020, https://www.wsj.com/articles/u-s-pays-high-prices-for-masks-from-unproven-vendors-in-coronavirus-fight-11587218400.
[3] The contracted supplier is Chinese automaker BYD which twice failed to secure NIOSH approval of the contracted masks, delaying delivery until June 2020. Contract between California and BYD: https://files.covid19.ca.gov/pdf/BYD-Motors-LLC-OES.pdf.
[4] Bonnie Berkowitz, “How Far Would a Million N95 Masks Go? It’s Complicated, and This Is Why.,” Washington Post, accessed July 31, 2020, https://www.washingtonpost.com/graphics/2020/health/virus-masks-ppe/.
[5]Premier, “Premier Inc. Survey: As COVID-19 Spreads to New Hotspots, Hospitals…,” Premier (Premier, July 31, 2020), https://www.premierinc.com/, https://www.premierinc.com/newsroom/press-releases/premier-inc-survey-as-covid-19-spreads-to-new-hotspots-hospitals-should-prepare-for-up-to-a-17x-surge-in-supply-demand.
[6] An alternative estimate can be derived from a Johns Hopkins modeling tool which estimates 57 million extra N95 masks needed for hospitals nationwide during 100 days of pandemic use. (Eric Toner, “Interim Estimate of US PPE Needs for COVID-19” (Johns Hopkins Center for Health Security, April 18, 2020), https://www.centerforhealthsecurity.org/resources/COVID-19/PPE/PPE-assumptions.) Pro-rating this to 90 days and assuming California would account for 12% of the nationwide use, this method would estimate a 90-day need for 6.2 million N95 masks in California hospitals. This estimate is only half of ours, but they assume that PPE protocol deviations due to shortages will continue despite the safety risk. We presume that the stockpile will instead be larger, sufficient for properly complying with PPE safety protocols.
[7]U.S. Department of Health and Human Services, “Hospital Personal Protective Equipment Planning Tool | Technical Resources,” ASPR TRACIE, accessed July 31, 2020, https://asprtracie.hhs.gov/technical-resources/resource/6457/hospital-personal-protective-equipment-planning-tool. The tool does not estimate the need for surgical masks, which we assume are needed in a ratio of 2 per N95.
[8] Maremont, Hufford, and McGinty, “U.S. Pays High Prices for Masks From Unproven Vendors in Coronavirus Fight.”
[9] Specifically, we price the 1860 model which is often used in healthcare. 3M, “Get the Facts: N95 Respirator Pricing,” Revised July 8, 2020, https://multimedia.3m.com/mws/media/1862179O/get-the-facts-n95-respirator-pricing.pdf. 3M “Surgical N95 vs. Standard N95 – Which to Consider?” June 2020, https://multimedia.3m.com/mws/media/1794572O/surgical-n95-vs-standard-n95-which-to-consider.pdf.
[10] Society for Healthcare Organization Procurement Professionals (SHOPP), “SHOPP PPD COVID Costs Analysis,” April 7, 2020, http://cdn.cnn.com/cnn/2020/images/04/16/shopp.covid.ppd.costs.analysis_.pdf.
[11] To the extent that new stockpile investments begin before current manufacturing capacity can be adequately increased to meet pandemic demand, some portion of the initial stockpile costs could be at pandemic rather than non-pandemic prices. For example, if the first 20% of the stockpile is purchased at pandemic prices, then the savings estimated here would be reduced by 20% – but would still be quite large.
[12] Sarah Bohn, Marisol Cuellar Majia, and Julien Lafortune, “Essential Workers and COVID-19,” Public Policy Institute of California (blog), March 31, 2020, https://www.ppic.org/blog/essential-workers-and-covid-19/.
[13] U.S. Bureau of Labor Statistics, U.S. Bureau of Labor Statistics, “California – May 2019 OES State Occupational Employment and Wage Estimates.”
[14] California Assembly Budget Committee, “Preliminary Review of the Governor’s Proposed 2012-2013 State Budget Act,” January 31, 2012, https://abgt.assembly.ca.gov/sites/abgt.assembly.ca.gov/files/reports/Preliminary%20Review%20of%20the%20Governor’s%20Proposed%202012-2013%20State%20Budget%20Act.pdf.
[15] State of California Executive Department, “Executive Order N-33-20,” March 19, 2020, https://www.gov.ca.gov/wp-content/uploads/2020/03/3.19.20-attested-EO-N-33-20-COVID-19-HEALTH-ORDER.pdf. U.S. Centers for Medicare and Medicaid Services, “Non-Emergent, Elective Medical Services, and Treatment Recommendations,” April 7, 2020, https://www.cms.gov/files/document/cms-non-emergent-elective-medical-recommendations.pdf.
[16] California Employment Development Department, “Initial Unemployment Insurance Claims data,” 2020.
[17] Thomas J Hedin, Geoffrey Schnorr, and Till Von Wachter, “An Analysis of Unemployment Insurance Claims in California During the COVID-19 Pandemic” (California Policy Lab, July 2, 2020), https://www.capolicylab.org/wp-content/uploads/2020/07/July-2nd-Analysis-of-UI-Claims-in-California-During-the-COVID-19-Pandemic.pdf.
[18] California Department of Public Health, “Resuming California’s Deferred and Preventive Health Care,” accessed July 31, 2020, https://www.cdph.ca.gov/Programs/CID/DCDC/Pages/COVID-19/ResumingCalifornia%E2%80%99sDeferredandPreventiveHealthCare.aspx. California Department of Public Health, “Guidance for Resuming Deferred and Preventive Dental Care,” May 7, 2020, https://www.cdph.ca.gov/Programs/CID/DCDC/Pages/Guidance-for-Resuming-Deferred-and-Preventive-Dental-Care–.aspx.
[19] American Medical Association, Letter to Federal Emergency Management Agency, June 30, 2020, https://searchlf.ama-assn.org/undefined/documentDownload?uri=%2Funstructured%2Fbinary%2Fletter%2FLETTERS%2F2020-6-30-Letter-to-Gaynor-re-PPE.pdf.
[20] California Department of Public Health, “State Officials Announce Latest COVID-19 Facts,” accessed August 9, 2020, https://www.cdph.ca.gov/Programs/OPA/Pages/NR20-190.aspx.
[21] This estimate is based on occupation-specific COVID-19 case data from Washington state, which is used to generate a ratio of cases between healthcare worker cases and other essential worker cases. See Technical Appendix for further details.
[22] The six countries were Hong Kong, Japan, Singapore, Taiwan, Thailand, and Vietnam. Fan-Yun Lan et al., “Work-Related COVID-19 Transmission in Six Asian Countries/Areas: A Follow-up Study,” PLOS ONE 15, no. 5 (May 19, 2020): e0233588, https://doi.org/10.1371/journal.pone.0233588.
[23] U.S. Centers for Medicare and Medicaid Services, “COVID-19 Nursing Home Dataset | Data.CMS.Gov,” July 23, 2020, https://data.cms.gov/Special-Programs-Initiatives-COVID-19-Nursing-Home/COVID-19-Nursing-Home-Dataset/s2uc-8wxp.
[24] Qin-Long Jing et al., “Household Secondary Attack Rate of COVID-19 and Associated Determinants in Guangzhou, China: A Retrospective Cohort Study,” The Lancet Infectious Diseases, accessed July 31, 2020, https://doi.org/10.1016/S1473-3099(20)30471-0.
[25] Los Angeles County Department of Public Health, “COVID-19 Positive Healthcare Workers and First Responders Data, Los Angeles County,” July 20,2020, http://publichealth.lacounty.gov/acd/docs/COVID19HCWReport.pdf.
[26]Farhaan S. Vahidy et al., “Prevalence of SARS-CoV-2 Infection Among Asymptomatic Health Care Workers in the Greater Houston, Texas, Area,” JAMA Network Open 3, no. 7 (July 1, 2020): e2016451–e2016451, https://doi.org/10.1001/jamanetworkopen.2020.16451.
[27] Healthcare worker training ensures that the vast majority of them would properly use PPE if available. Some non-healthcare essential workers may have insufficiently appreciated the importance of PPE, particularly early in the COVID-19 pandemic, thus we consider PPE availability as necessary but not sufficient to fully reduce transmission. Accompanying increased investments in public health outreach will also be crucial to fully realize the future potential for a PPE stockpile to avoid essential worker infections.
[28]Reina S Sikkema et al., “COVID-19 in Health-Care Workers in Three Hospitals in the South of the Netherlands: A Cross-Sectional Study,” The Lancet Infectious Diseases, July 2, 2020, https://doi.org/10.1016/S1473-3099(20)30527-2.
[29] Mingkun Zhan et al., “Death from Covid-19 of 23 Health Care Workers in China,” New England Journal of Medicine 382, no. 23 (June 4, 2020): 2267–68, https://doi.org/10.1056/NEJMc2005696.
[30] Temet M. McMichael et al., “Epidemiology of Covid-19 in a Long-Term Care Facility in King County, Washington,” New England Journal of Medicine 382, no. 21 (May 21, 2020): 2005–11, https://doi.org/10.1056/NEJMoa2005412.
[31] Richard M. Scheffler, Daniel R. Arnold, Brent D. Fulton, et al., “What are the Health Care Costs of COVID-19 in California?: State and County Estimates,” UC Berkeley Petris Center, June 25, 2020, https://petris.org/wp-content/uploads/2020/06/CA_COVID_Cost_Estimates.pdf.
[32] Chris Sloan, Nathan Markward, and Joanna Young, “COVID-19 Hospitalizations Projected to Cost up to $17B in US in 2020,” Avalere Health (blog), June 19, 2020, https://avalere.com/insights/covid-19-hospitalizations-projected-to-cost-up-to-17b-in-us-in-2020.
[33] Ignoring potential sick leave among the secondary cases, if we assume the 17,830 essential worker cases each resulted in 80 hours of sick leave at a conservatively estimated $20 per hour, this would total $28.5 million.
[34] California Department of Public Health, “State Officials Announce Latest COVID-19 Facts.”
[35] U.S. Centers for Medicare and Medicaid Services, “COVID-19 Nursing Home Dataset | Data.CMS.Gov.”
[36] Lisa A. Robinson, Ryan Sullivan, and Jason F. Shogren, “Do the Benefits of COVID-19 Policies Exceed the Costs? Exploring Uncertainties in the Age–VSL Relationship,” Risk Analysis, July 16, 2020, https://doi.org/10.1111/risa.13561.
[37] Kristof Stremikis, “COVID-19 Tracking Poll: Most Frontline Staff at California Nursing Homes See Infections at Work,” California Health Care Foundation (blog), July 17, 2020, https://www.chcf.org/blog/covid-19-tracking-poll-most-frontline-staff-nursing-homes-see-infections-work/.
[38] Governor Newsom, “Governor Newsom Announces Enhanced State Stockpile, Purchase of 420 Million New Protective Masks,” California Governor, July 22, 2020, https://www.gov.ca.gov/2020/07/22/governor-newsom-announces-enhanced-state-stockpile-purchase-of-420-million-new-protective-masks/.
[39] Washington State Department of Health and the Department of Labor & Industries Safety & Health Assessment & Research for Prevention (SHARP) program, “COVID-19 Confirmed Cases by Occupation and Industry,” June 12, 2020, https://www.doh.wa.gov/Portals/1/Documents/1600/coronavirus/covid_occupation_industry_summary_2020-06-12.pdf.
[40] California Department of Public Health, “State Officials Announce Latest COVID-19 Facts.”
[41] U.S. Centers for Medicare and Medicaid Services, “COVID-19 Nursing Home Dataset | Data.CMS.Gov,” July 23, 2020, https://data.cms.gov/Special-Programs-Initiatives-COVID-19-Nursing-Home/COVID-19-Nursing-Home-Dataset/s2uc-8wxp.
[42] Richard M. Scheffler, Daniel R. Arnold, Brent D. Fulton, et al., “What are the Health Care Costs of COVID-19 in California?: State and County Estimates,” UC Berkeley Petris Center, June 25, 2020, https://petris.org/wp-content/uploads/2020/06/CA_COVID_Cost_Estimates.pdf.
[43] Washington State Department of Health and the Department of Labor & Industries Safety & Health Assessment & Research for Prevention (SHARP) program, “COVID-19 Confirmed Cases by Occupation and Industry,” June 12, 2020, https://www.doh.wa.gov/Portals/1/Documents/1600/coronavirus/covid_occupation_industry_summary_2020-06-12.pdf.
[44] Qin-Long Jing et al., “Household Secondary Attack Rate of COVID-19 and Associated Determinants in Guangzhou, China: A Retrospective Cohort Study,” The Lancet Infectious Diseases, accessed July 31, 2020, https://doi.org/10.1016/S1473-3099(20)30471-0.
[45]Chris Sloan, Nathan Markward, and Joanna Young, “COVID-19 Hospitalizations Projected to Cost up to $17B in US in 2020,” Avalere Health (blog), June 19, 2020, https://avalere.com/insights/covid-19-hospitalizations-projected-to-cost-up-to-17b-in-us-in-2020.
[46] UCLA Center for Health Policy Research, “AskCHIS – California Health Interview Survey,” 2018.