Personal Protective Equipment Supply Chains Research Articles

La contribution des fournisseurs à la résilience de la chaîne logistique d'équipements de protection individuelle

AbstractThe disruptions experienced by the healthcare supply chain of personal protective equipment (PPE) during the COVID‐19 pandemic highlighted the importance of initiatives aimed at strengthening the resilience of this chain. This research takes the point of view of suppliers who were involved in the first months of the pandemic to fully understand their reading of events and thus be able to identify resilience initiatives to face future crises. The case under study is that of the PPE supply chain of the public healthcare and social services sector in the province of Quebec. Interviews with 23 suppliers were the main source of data, which was analyzed through the lens of social capital theory. This case study demonstrates that traditional resiliency initiatives such as safety stock or excess production capacity at suppliers would be better calibrated if buyers conducted a supplier market watch to anticipate major turbulence that could impact the supply chain.

Resilience of critical supply chains in pandemics: A model proposal for health personal protective equipment socially optimal distribution

The COVID-19 pandemic has tested the resilience of Supply Chains (SCs), which has faced many restrictions and affected their global response. Worldwide stockouts were witnessed due to SCs disruptions, which may endanger lives since some products are critical to responding to this global threat, such as ventilators and Personal Protective Equipment (PPE). Thus, this work aims to help deal with the pandemic impacts on critical SCs, addressing the distribution of materials that are used to cope with the pandemic and considering the resilience of its SCs, dealing with a gap of few studies combining simulation and optimization approaches to tackle this situation. We propose a dynamic framework based on a stochastic population model to address pandemic behavior and an optimization model to support decision-making in a PPE supply chain subject to a pandemic-driven disruption that can be updated anytime necessary. We develop a social objective function that aims to deliver PPE where they are most needed. The proposed approach is illustrated by an example involving real data from a Brazilian company that distributes PPE during the COVID-19 pandemic. We find that profit was inversely correlated with social gain, suggesting that optimizing profits is a poor strategy for addressing public health or social crisis. Still, our model furnishes results with an acceptable profit while prioritizing its effect on coping with the pandemic. As implications, our framework can be applied to support decision makers to improve SCs’ resilience and better allocate resources during disruptive circumstances in which the uncertainty is high, such as future pandemics.

Viability and Resilience in the Personal Protective Equipment Supply Chain. The Impacts of Covid-19

The recent Covid-19 pandemic has caused major disruptions in healthcare systems, in particular in the Personal Protective Equipment (PPE) supply chain. The present paper aims at studying the effects of Covid-19 on its main supply chain variables and at investigating how viability and resilience concepts were applied during this period. A Systematic Literature Review helps identify the variables and strategies most commonly considered, forming the basis of a survey then carried out among French and Italian companies operating in the PPE supply chain. The results allow to derive both academic and practical implications.

Pivoting and pandemics: A game-theoretic framework for agile personal protective equipment supply chains

Supply chain models frequently tackle manufacturing issues but must also account for the distinctive nature of the disease. Conversely, most epidemiological models solely concentrate on the disease’s spread but must address logistical challenges. The medical supply chain encounters numerous problems during a pandemic, requiring adaptation through pivoting strategies. For instance, when the COVID-19 outbreak began, several nations prohibited the export of medical supplies, including personal protective equipment (PPE). Consequently, in times of crisis, many countries adopt a localization strategy that encourages domestic companies to adapt their operations and produce medical items. Nevertheless, an interconnected system is essential to align suppliers with the actual demand for medical supplies. This study focuses on the design of a game model for the supply chain that considers manufacturers’ equilibrium behaviors in response to the real demand for medical items. We propose a game model that incorporates both the medical supply chain and the unique characteristics of pandemics. Various decisions are taken into account, such as production volume, actual demand for medical products, price, distribution of medical supplies, and investment costs in manufacturing technologies. To determine the Nash Equilibrium solutions for the proposed game model, the Variational Inequality (VI) theory is implemented.

Advertising with Anonymity and Impunity: The Harmful Consequences of Counterfeit PPE Supply Chains

The rapid growth of illicit supply chains during and after the Covid-19 pandemic reveals a need for effectively combating and preventing the cross-border movement of contraband, including but not limited to counterfeit goods. A proactive approach by companies along with public stakeholders, such as government agencies and individual consumers, toward disrupting illicit supply chains operating across borders is especially important during moments of global crisis when consumers are more susceptible to unknowingly purchasing substandard counterfeit products such as respirators. While marketplaces, platforms, and other legitimate businesses have worked to prevent movement of counterfeits and illicit goods through their services, the high adaptability and sophistication of counterfeiters requires more preventative and multistakeholder approaches. This article outlines a multidisciplinary and multilayered approach to detecting and disrupting illicit supply chains of counterfeit personal protective equipment (PPE) with a focus on respirators. It utilizes research conducted for a National Science Foundation (NSF) grant on Covid-19 related crime, including the advertising and sale of counterfeit respirators. One layer examines online content as seen by the end user and the activity of vendors or sellers used to advertise and sell counterfeit products. The research is also informed by data on the information, financial, and physical flows of counterfeit respirators obtained through a public-private partnership with George Mason University’s Terrorism, Transnational Crime and Corruption Center (TraCCC-GMU) and 3M, one of the largest manufacturers of respirators in the world. The article examines an important and relatively recent trend - how emerging technological shifts in the marketplace are affecting global security. Research from the TraCCC-GMU and 3M partnership, including a data sharing agreement, revealed that counterfeiters constantly change their modus operandi to continue selling illicit goods with impunity, facilitating illicit activity with the use and abuse of legitimate companies such as ecommerce marketplaces and social media. The article presents an overview of the current state of counterfeit supply chains and provides concrete policy recommendations on how legitimate companies can move beyond just removing listings but must also actively prevent these transnational crimes through innovative multidisciplinary approaches, advanced data analytics, and public awareness campaigns. The research also seeks to connect the dots to broader policy implications in terms of the legitimate economy and environmental sustainability.

Australian emergency nurses' experiences of working with personal protective equipment during the COVID-19 pandemic. A qualitative study

IntroductionThe COVID-19 pandemic has exposed a need to understand the challenges associated with wearing Personal protective Equipment (PPE). The aim in this study was to explore emergency nurses’ experiences early in the COVID-19 pandemic in Australia and the impact of PPE use on their practice. MethodsAn explorative descriptive qualitative study was conducted between January 2022 and April 2022. Eighteen emergency nurses and six leaders participated. Semi-structured interviews (n = 21) and one focus group were conducted. Interview transcripts were analysed using Braun and Clarke’s framework. ResultsTwo major themes were identified. The first theme was: (1) The shifting ground of the COVID-19 pandemic response. Associated sub-themes were: i) What’s the go with PPE today? ii) In the beginning we were scrambling for masks; iii) Emergency is the true frontline. The second theme was: (2) Physical and emotional impacts of emergency nursing work. Sub-themes were: (i) Facing the fear of exposure; (ii) By the end of the shift I am just absolutely spent; iii) Discomfort of wearing PPE impacts on compliance. ConclusionsHealthcare leaders need to secure PPE supply chains and evaluate the effectiveness and side-effects of different PPE designs to minimise occupational harms associated with prolonged PPE use.

The economic value of personal protective equipment for healthcare workers.

In this paper, we examine the cost effectiveness of investment in personal protective equipment (PPE) for protecting health care workers (HCWs) against two infectious diseases: Ebola virus and methicillin-resistant Staphylococcus aureus (MRSA). This builds on similar work published for COVID-19 in 2020. We developed two separate decision-analytic models using a payer perspective to compare the costs and effects of multiple PPE use scenarios for protection of HCW against Ebola and MRSA. Bayesian multivariate sensitivity analyses were used to consider the uncertainty surrounding all key parameters for both diseases. We estimate the cost to provide adequate PPE for a HCW encounter with an Ebola patient is $13.04, which is associated with a 97% risk reduction in infections. The mean incremental cost-effectiveness ratio (ICER) is $3.98 per disability-adjusted life year (DALY) averted. Because of lowered infection and disability rates, this investment is estimated to save $132.27 in averted health systems costs, a financial ROI of 1,014%. For MRSA, the cost of adequate PPE for one HCW encounter is $0.88, which is associated with a 53% risk reduction in infections. The mean ICER is $362.14 per DALY averted. This investment is estimated to save $20.18 in averted health systems costs, a financial ROI of 2,294%. In terms of total health savings per death averted, investing in adequate PPE is the dominant strategy for Ebola and MRSA, suggesting that it is both more costly and less clinically optimal to not fully invest in PPE for these diseases. There are many compelling reasons to invest in PPE to protect HCWs. This analysis examines the economic case, building on previous evidence that protecting HCWs with PPE is cost-effective for COVD-19. Ebola and MRSA scenarios were selected to allow assessment of both endemic and epidemic infectious diseases. While PPE is cost-effective for both conditions, compared to our analysis for COVID-19, PPE is relatively more cost-effective for Ebola and relatively less so for MRSA. Further research is needed to assess shortfalls in the PPE supply chain identified during the COVID-19 pandemic to ensure an efficient and resilient supply in the face of future pandemics.

Establishing local manufacture of PPE for healthcare workers in the time of a global pandemic

A face shield is a secondary personal protective equipment (PPE) for healthcare workers (HCW). Worn with the appropriate face masks/respirators, it provides short term barrier protection against potentially infectious droplet particles. Coronavirus disease 2019 (COVID-19) caused a spike in demand for PPE, leading to a shortage and risking the safety of HCW. Transport restrictions further challenged the existing PPE supply chain which has been reliant on overseas-based manufacturers. Despite the urgency in demand, PPE must be properly tested for functionality and quality. We describe the establishment of local face shields manufacture in Western Australia to ensure adequate PPE for HCW. Ten thousand face shields for general use (standard) and for ear, nose and throat (ENT) specialist use were produced. Materials and design considerations are described, and the face shields were vigorously tested to the relevant Standards to ensure their effectiveness as a protective barrier, including splash and impact resistance. Comparative testing with traditional and other novel face shields was also undertaken. Therapeutic Goods Administration (TGA) licence was obtained to manufacture and supply the face shields as a Class I medical device. The swiftness of process is a credit to collaboration from industry, academia and healthcare.

Design, Implementation, and Evaluation of an N95 Respirator Decontamination and Reuse Program for Healthcare Workers During the COVID-19 Pandemic

Early in the COVID-19 pandemic, substantial disruptions in personal protective equipment (PPE) supply chains forced healthcare systems to become resourceful to ensure PPE availability for healthcare workers. Most worrisome was the global shortage of N95 respirators. In response, a collaboration between the Department of Infection Control and Healthcare Epidemiology and the Department of Biosafety at the University of Texas Medical Branch developed a PPE recycling program guaranteeing an adequate supply of respirators for frontline staff. The team successfully developed and implemented a novel workflow that included validated decontamination procedures, education, and training programs as well as transportation, labeling, and storage logistics. In total, 15,995 respirators of various types and sizes were received for recycling. Of these, 12,752 (80%) were recycled. Following the program's implementation, we surveyed 134 frontline healthcare workers who overwhelmingly graded our institution's culture of safety positively. Overall impressions of the N95 respirator recycling program were mixed, although interpretation of those results was limited by a lower survey response rate. In an era of increasing health security threats, innovative recycling programs like this one may serve as a model for other health systems to respond to future PPE supply chain disruptions.

Desafios da Segurança da Saúde Global em tempos de pandemia: O acesso a Equipamentos de Proteção Individual na crise da covid-19

Abstract This article addresses the precariousness of the Global Health Security system, focusing on the distribution of Personal Protective Equipment (PPE) during health crises and taking the COVID-19 pandemic as a departure point and a center. The shortage of PPE was exacerbated by factors such as the high transmission rate of the virus, inadequate training on its use and disposal, flexibility in guidelines regarding prolonged use and reuse of equipment, and restrictions on the export of healthcare products. The collapse of the global PPE supply chain has exposed frontline healthcare workers, especially in low- and middle-income countries, due to inadequate healthcare infrastructure and socioeconomic disparities. The lack of effective action to maintain and equitably distribute existing PPE stocks further exacerbated their shortage, compromising the effective response to the pandemic. To strengthen the resilience of healthcare systems, strategies need to be developed to ensure safety and equity in the global supply chain of healthcare products, with interconnected and redundant networks of suppliers. International collaboration and investments in multilateral mechanisms play a crucial role in building a more resilient Global Health Security.

Mitigating personal protective equipment (PPE) supply chain disruptions in pandemics – a system dynamics approach

PurposeThe coronavirus disease (COVID-19) pandemic has emerged as an unprecedented health crisis worldwide and heavily disrupted the healthcare supply chain. This study focuses on analysing the different types of disruptions occurring in personal protective equipment (PPE) supply chains during the COVID-19 pandemic and on proposing mitigation strategies that are fit to the global scale and many interdependencies that are characteristic for this pandemic. The authors construct a conceptual system dynamics model (SD) based on the literature and adjusted with the use of empirical data (interviews) to capture the complexity of a global supply chain and identify leverage points (mitigation strategies).Design/methodology/approachThis research follows a mix-methods approach. First, the authors developed a conceptual framework based on four types of disruptions that usually occur during health emergencies (direct effect, policy, supply chain strategy, and behaviourally induced disruptions). Second, the authors collected and analysed data from interviews with experts in the PPE supply chain. Based on the interviews data, the authors developed a conceptual system dynamics (SD) model that allows to capture the complex and dynamic interplay between the elements of the global supply chain system, by highlighting key feedback loops, delays, and the way the mitigation strategies can impact on them. From this analysis, the authors developed four propositions for supply chain risk management (SCRM) in global health emergencies and four recommendations for the policy and decision makers.FindingsThe SD model highlights that without a combination of mitigation measures, it is impossible to overcome all disruptions. As such, a co-ordinated effort across the different countries and sectors that experience the disruptions is needed. The SD model also shows that there are important feedback loops, by which initial disruptions create delays and shortages that propagate through the supply chain network. If the co-ordinated mitigation measures are not implemented early at the onset of the pandemic, these disruptions will be persistent, creating potential shortages of PPE and other critical equipment at the onset of a pandemic – when they are most urgently needed.Originality/valueThis research enriches the understanding of the disruptions of PPE supply chains on the systems level and proposes mitigation strategies based on empirical data and the existing literature.

Ensuring Market Supply Transparency for Personal Protective Equipment: Preparing for Future Pandemics

AbstractThe COVID‐19 pandemic has exposed the opacity of the global personal protective equipment (PPE) supply chain. Dependence on international markets for medical PPE provision has left states vulnerable to price volatility and supply shortages. As the severity of the pandemic fluctuates amidst an ever‐present risk of regional and global public health crises, medical PPE market volatility – exacerbated by the lack of accurate, up‐to‐date, transparent information of PPE international supply conditions – will continue to undermine effective policy responses and the resilience of healthcare systems around the world. This article proposes a WTO/WHO joint initiative to ensure PPE market supply transparency for future pandemic preparedness. It departs from an analysis of the global PPE market, the impact of COVID‐19 on PPE production and supply, and the systemic lack of basic PPE supply chain information at all levels. From this, it identifies the need for PPE market supply transparency and thus proposes creating a PPE market supply transparency system at the domestic and/or international level as a viable solution to enhance transparency and cooperation in preparation for the next pandemic.

Facing disruption: Learning from the healthcare supply chain responses in British Columbia during the COVID-19 pandemic.

The healthcare supply chain crisis surrounding Personal Protective Equipment (PPE) during the onset of the COVID-19 pandemic presented unique and complex challenges in achieving the primary aim of supply chain management, that is, delivering the right amount of the right supplies to the right people at the right time. This article describes the key findings from a case study on PPE supply chain responses to the COVID-19 pandemic in British Columbia (BC). It highlights a set of constructive response mechanisms to potential crises along healthcare supply chain. Effective and trusted leadership, a unity of purpose, integrated and robust digital infrastructure and capabilities, consistent learning, resilience building, and environmental sensing for reliable intelligence were found to be essential for preparing, for containing, and mitigating the crisis as it evolved across various phases of crisis management.

Blockchain-based Supply Chain Traceability for COVID-19 personal protective equipment

The COVID-19 pandemic has severely impacted many industries, in particular the healthcare sector exposing systemic vulnerabilities in emergency preparedness, risk mitigation, and supply chain management. A major challenge during the pandemic was related to the increased demand for Personal Protective Equipment (PPE), resulting in critical shortages for healthcare and frontline workers. This is due to the lack of information visibility combined with the inability to precisely track product movement within the supply chain, requiring a robust traceability solution. Blockchain technology is a distributed ledger that ensures a transparent, safe, and secure exchange of data among supply chain stakeholders. The advantages of adopting blockchain technology to manage and track PPE products in the supply chain include decentralized control, security, traceability, and auditable time-stamped transactions. In this paper, we present a blockchain-based approach using smart contracts to transform PPE supply chain operations. We propose a generic framework using Ethereum smart contracts and decentralized storage systems to automate the processes and information exchange and present detailed algorithms that capture the interactions among supply chain stakeholders. The smart contract code was developed and tested in Remix environment, and the code is made publicly available on Github. We present detailed cost and security analysis incurred by the stakeholders in the supply chain. Adopting a blockchain-based solution for PPE supply chains is economically viable and provides a streamlined, secure, trusted, and transparent mode of communication among various stakeholders.

Applying blockchain technology to ensure compliance with sustainability standards in the PPE multi-tier supply chain

Because of the Covid-19 pandemic, urgent surging demand for healthcare products such as personal protective equipment (PPE) has caused significant challenges for multi-tier supply chain management. Although a given firm may predominantly focus on an arms-length solution by targeting the first-tier supplier, the firm can still struggle with extended multi-tier suppliers it cannot choose which use unsustainable practices. One key goal is compliance across various dimensions with production, environmental and labour standards across the multi-tier supply chain, a goal that blockchain technology can be applied to manage. Based on a comprehensive literature review, this research develops a system architecture of blockchain-based multi-tier sustainable supply chain management in the PPE industry designed to identify and coordinate standards in production and social and environmental sustainability in multi-tier PPE supply chains. The architecture was validated by theoretical basis, expert opinions and technical solutions. We conclude with managerial implications for implementing blockchain technology to advance sustainable multi-tier supply chain practices.

Environmental Impacts of Personal Protective Clothing Used to Combat COVID- 19.

Personal protective clothing is critical to shield users from highly infectious diseases including COVID‐19. Such clothing is predominantly single‐use, made of plastic‐based synthetic fibers such as polypropylene and polyester, low cost and able to provide protection against pathogens. However, the environmental impacts of synthetic fiber‐based clothing are significant and well‐documented. Despite growing environmental concerns with single‐use plastic‐based protective clothing, the recent COVID‐19 pandemic has seen a significant increase in their use, which could result in a further surge of oceanic plastic pollution, adding to the mass of plastic waste that already threatens marine life. In this review, the nature of the raw materials involved in the production of such clothing, as well as manufacturing techniques and the personal protective equipment supply chain are briefly discussed. The environmental impacts at critical points in the protective clothing value chain are identified from production to consumption, focusing on water use, chemical pollution, CO2 emissions, and waste. On the basis of these environmental impacts, the need for fundamental changes in the business model is outlined, including increased usage of reusable protective clothing, addressing supply chain “bottlenecks”, establishing better waste management, and the use of sustainable materials and processes without associated environmental problems.

How COVID‐19 Medical Supply Shortages Led to Extraordinary Trade and Industrial Policy

Early in the COVID‐19 pandemic, a global shortage of hospital gowns, gloves, surgical masks, and respirators caused policymakers globally to panic. China increased imports and decreased exports of this personal protective equipment, removing supplies from world markets. Shortages led to European Union and US export controls as well as other extraordinary policy actions, including a US effort to reserve supplies manufactured in China by a US‐headquartered multinational. By April 2020, China's exports had mostly resumed, and over the rest of the year its export volumes surged. But China's export prices also skyrocketed and remained elevated through 2020, reflecting severe and continued shortages. This paper explores these and other government actions, such as US trade war tariffs and US industrial policy in the form of over $1 billion of subsidies to build out its domestic personal protective equipment supply chain, as well as potential lessons for future pandemic preparedness and international policy cooperation.

Self-Reported Use of Personal Protective Equipment among Emergency Department Nurses, Physicians and Advanced Practice Providers during the 2020 COVID-19 Pandemic.

Background: Emergency departments (EDs) have seen dramatic surges in patients infected with COVID-19 and are high-risk transmission environments. Knowledge, attitudes and practice regarding personal protective equipment (PPE) among ED health care workers (HCWs) during the COVID-19 pandemic have not been studied, thus this study examines this knowledge gap. Methods: This was a cross-sectional survey of 308 HCWs in two urban EDs in Atlanta, Georgia in April and May of 2020. Results: We surveyed 308 HCWs; 137 responded (44% response rate). All HCWs reported adequate knowledge and 96% reported compliance with PPE guidelines. Reported sources of PPE information: 56.7% charge nurse, 67.3% the institutional COVID-19 website. Frequency of training was positively associated with understanding how to protect themselves and patients (OR = 1.7, 95% CI: 1.0–2.9). Conclusions: Few HCWs are willing to care for patients without PPE, and therefore we should aim for resiliency in the PPE supply chain. EDs should consider multiple communication strategies, including a website with concise information and enhanced training for key personnel, particularly the charge nurse. Attention to frequency in HCW training may be key to improve confidence in protecting themselves and patients. Findings can be leveraged by EDs to implement effective PPE training.

재료 압출 공정을 이용한 재사용 가능 안면 보호구 개발에 관한 연구

Due to the pandemic of SARS-CoV-2 (COVID-19) virus, the demand for personal protective equipment (PPE), including face shield, ventilator value, and so on, has abruptly increased in the world. The collapse of the global supply chain of PPE has led to a shortage of the PPE. An additive manufacturing process has emerged as one of solutions to overcome such shortage. The objective of this study was to develop a reusable protective face shield using a material extrusion (ME) process. Five types of face shield were designed. Effects of the design on effective stress distribution, deformation, and specific rigidity were investigated through finite element analyses. To examine the influence of the design on deposition and post-processing characteristics, five types of face shield were fabricated from a ME apparatus. Post-processing characteristics and building time were greatly improved when Design 1 was adopted. In addition, the overall weight, wasted material, and buy-to-fly (BTF) ratio were significantly reduced when Design 1 was applied. Finally, results of wearing and droplet spreading experiments showed that the fabricated face shield for Design 1 was applicable to protection of droplet spreading.

Rebuilding Global Plastic Surgery Services and Safeguarding Workforce Density after COVID-19.

A recent report has found that approximately 150,000 health care workers have been infected with the SARS-CoV-2 virus, resulting in more than 1400 deaths.1 Of the 32 reported deaths of doctors in the United Kingdom due to coronavirus disease of 2019 (COVID-19), one was a plastic surgeon.2 Although the loss of any colleague is tragic, this pandemic will have an unprecedented and disproportional effect on low-income and middle-income countries and our collective global surgery aspirations. Recently, an extensive scoping review of health care workers’ COVID-19–related infections and deaths worldwide was published.1 Interestingly, the majority of documented health care worker deaths were seen in specialties not routinely associated with exposure to oronasal secretions, thereby highlighting the risk to all surgeons, including our plastic surgery community.1 While in the United Kingdom there are approximately 900 plastic surgeons, with over one surgeon per 100,000 people, the majority of countries worldwide are not as well equipped. For example, in Malawi, there are only three qualified plastic surgeons, representing 0.01 surgeons per 100,000 people.3 These figures are consistent across the multitude of low- and middle-income countries. The implications, therefore, of COVID-19 on the plastic surgery workforce in such countries are striking, with one death in Malawi representing a loss of 33 percent of the qualified plastic surgeons. The Lancet Commission on Global Surgery revealed the importance of an adequate surgical, obstetric, and anesthesia workforce density, due to a clear positive association between surgical, obstetric, and anesthesia workforce density and reduced morbidity and mortality rates and increased life expectancy.4The Lancet commission’s target of at least 20 surgical workers per 100,000 aimed to provide equality in health system staffing and patient outcomes.4 However, as many of our plastic surgery colleagues around the world (and particularly in low- and middle-income countries) are working exclusively as COVID-19 doctors, plastic surgery units are being converted to COVID units (e.g., the biggest plastic surgery specialist hospital in the world, with 500 beds and based in Dhaka, Bangladesh, is currently used solely for COVID-19), and personal protective equipment remains sparse and supply chains broken, we must act swiftly and in unison to safeguard global plastic surgery.5 The current global consequences of COVID-19 and restrictions in travel have strained traditional means of workforce training and attempts to improve surgical, obstetric, and anesthesia workforce density. However, biopsychosocial, economic, and ethical arguments should continue to compel us to overcome these challenges. Moving forward, we must focus on promoting safe working practices and preventative measures (such as advocating for safe and resilient personal protective equipment supply chains) and supporting our plastic surgery colleagues in low- and middle-income countries. Plastic surgery training in low- and middle-income countries must continue, and may require further development of our virtual teaching, e-learning, webinar, and simulation resources. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article.