Part of Pandemic-Proof, Future Perfect’s series on the upgrades we can make to prepare for the next pandemic.

Some of the most indelible images of the early pandemic were of the personal protective equipment (PPE) crisis in our hospitals — photos of doctors and nurses wearing repurposed garbage bags, swim goggles, and snorkeling masks as the supply of PPE dwindled in the face of Covid-19’s assault.

Those images underscored just how unprepared we were to deal with a fast-moving pandemic. US hospitals relied heavily on overseas suppliers, especially in China, for PPE, and there are no regulations requiring hospitals or states to keep a certain level of stock in case of a crisis. Most didn’t; US health care operates under tight financial pressures, and just-in-time sourcing is — in normal times — more cost-effective. The result was a supply crunch that hampered our response against the pandemic.

As the country waited for US manufacturers to scale up PPE production and for supply chains to stabilize, a fascinating stopgap solution emerged: 3D printing. In the face of a shortage of masks, a coalition of private, public, and volunteer groups coalesced to fill a void, their efforts centered on producing and distributing 3D-printed masks.

Their work, to be sure, was not nearly enough to meet the shortfall. But as a stopgap, they undoubtedly helped, especially at the local level where such operations were focused — and it all suggests a limited but promising role for 3D printing in the fight against future pandemics.

“The Wild West of PPE”

It is hard to overstate just how terrible the PPE crisis of the early days of the pandemic was, especially for the health care workers at the front lines of the crisis.

The shortage led to a fierce search for masks and other equipment that pitted hospitals and states against one another. John Hick, medical director for emergency preparedness at Hennepin Healthcare in Minnesota, recalls the lengths to which his hospital needed to go to secure shipments from the increasingly insufficient stock. “We knew the supply chain was not going to be able to keep up with the pandemic. And it didn’t,” he told me.

Meanwhile, supply companies in China tried to work around the export restrictions put in place by the Chinese government early in the pandemic. “When we were receiving samples of masks and gowns from China,” Hick told me, “a lot of times they would come in a box wrapped in clothing, so that from an export standpoint, it would look like they were sending those and not PPE.”

Premier Inc, a health care supply company, told me that orders rose 17-fold in the early days of Covid-19, and that hospitals all over the country were sending representatives overseas in a frantic attempt to buy up any remaining supplies they could. Sometimes they were lucky, but personnel unfamiliar with the process and without preexisting relationships with vendors often returned with counterfeit products — or sometimes nothing at all.

It was the “Wild West of PPE,” remembers Hick.

That’s where 3D printing came in.

The promise of printing PPE in a pandemic crisis

3D printers can make solid, three-dimensional objects from digital designs. Following a digital blueprint, material like plastics or metal powders are laid down in successive layers, one added after another — one reason why 3D printing is also known as additive manufacturing.

Given enough raw material and a digital design to work from, 3D printers can manufacture physical objects like face shields and masks within a few minutes or hours. It’s far from perfect — additive manufacturing has generally been relied on more for prototyping designs than full-scale manufacturing — but the desperate need for PPE early in the pandemic provided an opportunity to push the limits of 3D printing technology.

This is exactly what the COVID 3D Trust project tried to facilitate, once the shortages of PPE became clear early on in the pandemic. The group was founded under the umbrella of the National Institutes of Health (NIH) 3D Print Exchange, a program the agency launched in 2014 to support bioscience research; they mainly printed 3D models of molecules being studied in biology research labs.

They already had the necessary infrastructure and were able to work closely with the Food and Drug Administration (FDA) and the Department of Veterans Affairs (VA) to support cutting-edge biomedical work, printing masks and face shields for health care workers. In just 10 days in March 2020, they were able to provide a platform that would host a crowdsourced repository of 3D-printed designs for masks, face shields, and other supplies such as nasal swabs for testing — all of them tested by the VA to meet the FDA’s emergency use authorization standards for PPE.

Meanwhile, the Advanced Manufacturing Crisis Production Response, (AMCPR) Exchange, a website platform run by America Makes (a public-private partnership for promoting innovative work like 3D printing), provided a separate platform to connect small-scale manufacturers to buyers. According to Meghan McCarthy, the program lead at the NIH 3D Print Exchange, the demand was clear: Traffic to the COVID 3D Trust site jumped rapidly, from 15,000 users per month before the pandemic to 30,000 users per day in March 2020.

The AMCPR’s success relied on individuals, volunteer groups, university organizations, and commercial entities that stepped up to contribute their local 3D printing capacity toward providing PPE needed for the Covid-19 response efforts.

Among them was the Illinois PPE Project, a volunteer-led effort that came together when the urgent need for PPE in nearby hospitals became glaring and the response from established institutions proved lackluster. The project was able to arrange for veterans to make product deliveries, use donated loading dock space from local companies, and rely on volunteer efforts to call hospitals and find out who had the most pressing needs.

A report put together by America Makes estimated that its effort produced and delivered 38 million face shields and face shield parts, over 12 million Covid-19 diagnostic nasal swabs, over 2 million ear savers, and hundreds of thousands of mask components and ventilator parts. (The ear saver is an attachment that can be used to make masks more comfortable by removing pressure from the ears. That may not matter to the average person temporarily wearing a mask as they dip into a store, but it is highly relevant to health care providers, who often have to wear a mask for the entirety of a 12-hour shift.)

Nation of Makers, a nonprofit founded to support the “maker” community — a subculture oriented around engineering new hardware and tinkering, often through the use of 3D printing — estimates that nearly 50 million total units of PPE and other medical supplies were produced for the Covid-19 response by local additive manufacturing groups by January 2021. It’s an eye-popping number — though still small in the context of domestic mass manufacturing and total demand within the health care system; in March 2020, the US Department of Health and Human Services contracted with companies for 600 million N95 masks to be delivered over an 18-month period.

A stopgap, not a solution

As those figures suggest, 3D printing is inherently small-scale. It’s not a long-term solution for meeting the PPE demand in the health care system, and will never be as cost-effective at scale as traditional mass manufacturing. Its main value is that it can be done locally, with minimal lead time, and can temporarily fill in the gap to buy time for larger-scale manufacturing and shipping to catch up.

3D printing also has value as a means of prototyping new PPE designs. Digital designs can be quickly revised during the additive manufacturing process to try out new approaches. One notable success during this pandemic was the stopgap surgical mask, a sterilizable mask with a replaceable filter that meets FDA standards and is currently going through the CDC’s NIOSH approval process for N95 masks.

Other promising projects made it to the prototype stage; in particular, the Bellus3D app (which is unfortunately now shutting down) hoped to offer a service for scanning an individual’s face to be combined with 3D printing to create a custom-fitted reusable and sterilizable mask, or a customizable plastic frame to improve the seal of a surgical mask.

But additive manufacturing is just that: additive. Preparing for the next pandemic will require reforming supply chains and enhancing emergency stockpiling for conventionally made PPE as well.

The wish list of upgrades is long: moving away from just-in-time shipping when it comes to PPE; tax incentives or hospital regulations to incentivize PPE production year-round; and new mechanisms to improve visibility of PPE supplies and chains across hospitals and states, among many others.

But we now have a grasp of the limits of 3D printing in an emergency and how much more we can push them. It almost certainly saved some lives this time around, and it may well be even more consequential in the next pandemic.