Emanuel Simhayev's small pharmacy is short-staffed these days.
Most of his employees, worried about getting exposed to the coronavirus, are no longer coming to work. Simhayev, 33, and his technician Evelyn Quirindongo, 53, are now scrambling to meet the surging demand for medication and other essentials at Get Well Rx Pharmacy in Astoria, Queens.
As tens of thousands of people test positive in New York City and many more show symptoms and are presumed to have the virus, communities are turning to their neighborhood pharmacies for prescription and over-the-counter medicines to alleviate their symptoms.
The unprecedented demand created by the global pandemic is creating shortages for even basic over-the-counter drugs like Tylenol, as supply chains strain from the manufacturers that produce the medications to the wholesalers that deliver them to pharmacies, making it extraordinarily difficult to keep shelves fully stocked for key items in hot zones like New York.
"I never thought a pharmacy in the 21st century can run out of essentials, the most basic medications," Simhayev said. "When you face this hardship you cannot really help much. You do your best."
It's not just Tylenol that's hard to come by. The drug, made by Johnson & Johnson's McNeil Consumer Healthcare, is on backorder until April 30 at Broadway Chemists on the Upper West Side. Sophia Liristis, the pharmacist in charge there, said most medications and medical devices used to combat the virus are currently on backorder or are rationed out by wholesalers in limited quantities.
When Liristis, 34, checked the system Tuesday, thermometers, gloves and masks were not available until May. Pulse oximeters, used to monitor blood-oxygen levels, were unavailable until May 31. Ventolin inhalers, which can ease shortness of breath, were only available two units at a time.
The two most talked about drugs, which have inspired some hope as possible treatments for the virus, are also in short supply. A study in France concluded that hydroxychloroquine, usually used to treat malaria and autoimmune diseases, was particularly effective in fighting the virus when used in combination with the antibiotic azithromycin, though those results have been disputed. New York state is now conducting its own clinical trials.
Effective or not in the fight against COVID-19, hydroxychloroquine is on backorder, and azithromycin, often sold under the brand name Zithromax Z-pak, is in very limited supply and almost unavailable, according to Liristis' records.
S Bros Pharmacy in Brooklyn's Williamsburg neighborhood filled its inventory with hydroxychloroquine and Z-paks when word spread the drugs were a possible treatment. But the pharmacy is now dispensing hydroxychloroquine only to patients who suffer from chronic autoimmune diseases to meet guidelines set by New York state, which limit the drug to FDA-approved therapies and COVID-19-positive patients participating in the state trials to ease shortages.
S Bros' shelves are also scarce in Tylenol while hand sanitizer, vitamin and zinc supplements and cleaning supplies like alcohol and peroxide are long gone. Staff was excited to receive a few cans of Lysol spray so they can disinfect the store more often than once a night.
"There's a shortage of everything — it's never enough," said Evangeline Frezoulis, 37, the pharmacy manager at S Bros. "The wholesalers are not able to supply as many pharmacies as needed."
When Broadway Chemists doesn't have an item in stock, Liristis tells customers to check with chain pharmacies, even though that hurts business for smaller, family-owned stores.
"You're just trying to help the patient get what they need," Liristis said. "It doesn't matter if it's here or somewhere else — we're just trying to work together."
Pharmacies are improvising when they can. City Drug & Surgical in Manhattan's Washington Heights neighborhood has been making hand sanitizer since the brand names sold out about three weeks ago. Yelena Yoffe, the pharmacy owner, said it takes about 40 minutes to make a batch of 24 bottles. They sell out the same day.
AmerisourceBergen, a pharmaceutical wholesaler, said the pandemic is pinching supply chains worldwide. As the company places large orders to meet surging U.S. demand, manufacturers in countries like India, which is under nationwide lockdown, are balancing those orders with obligations in regions like the European Union, which is also severely impacted.
"What we're seeing in the supply chain today particularly from the pharmacy side is an insatiable demand for a limited amount of product," said Heather Zenk, senior vice president of secure supply chain at AmerisourceBergen. "We are seeing manufacturers talk about things like historical inventory demands and historical product movement," she said.
In response, AmerisourceBergen is limiting how much pharmacies receive of certain drugs to ensure they get at least some product, a policy the company calls "fair allocation."
Cardinal Health, another major wholesaler, said it's managing the distribution of more than 100,000 products considered critical inventory which are in unprecedented demand since the pandemic started to spread. "We are experiencing backorders and declining inventory levels at rates never experienced before," the company said, in a website statement, warning that customers may only receive partial deliveries while other products are out of stock altogether.
As the virus spreads, pharmacies are doing what they can to protect employees from exposure and enforce social distancing. At Get Well Rx in Queens, Simhayev has signs posted asking customers to wear masks and enter two at a time, but it's tough to get everyone to notice and follow the rules. So, he keeps his door open to accommodate the line and create space so the store doesn't become overcrowded.
Queens has been particularly hard hit by the virus with 34% of the more than 52,000 confirmed infections in the city as of Friday. In Simhayev's area of Astoria, at least 144 people have tested positive, according to data released by the New York City Department of Health on Wednesday. The number of infections is likely higher as testing remains limited.
Simhayev said a woman came to his pharmacy panicking earlier in the week and cut to the front of the line asking for medication to treat her husband's cough and shortness of breath. Simhayev sent them to the doctor next door and an ambulance was ultimately called for the man, who is in his 40s and was presumed positive.
"You have things like this happening, and you have a line of people waiting," Simhayev said. "When you work in times like this, it's an epidemic that you never even imagined was possible."
Some pharmacies are no longer open to foot traffic. Broadway Chemists shifted to delivery only to prevent the small store from overcrowding and keep employees safe from exposure. The pharmacy's neighborhood has at least 204 confirmed cases of the virus, according to city data.
"Small stores can't afford to get infected," Liristis said. "If one person gets infected, we'd have to shut our doors and not be able to accommodate the community."
Frezoulis said S Bros has probably served hundreds of customers that have tested positive or are presumed positive. City data shows at least 601 confirmed cases in the neighborhood. She said that while the situation is frightening and each day brings uncertainty, the pharmacy staff maintains calm to reassure the public.
"If we don't stay calm, everyone will panic with us," Frezoulis said.
At Best Five Star Pharmacy in the Corona neighborhood of Queens, employees lock the door to ensure only two customers enter the store at a time. Corona is one of the hardest hit neighborhoods in the city with at least 947 people testing positive, according to city data. Five Star is close to Elmhurst Hospital, where nurses and ER doctors are on the front line in the fight against the outbreak, grappling with a dramatic surge in seriously ill patients requiring intensive care.
Yitzy Engelberg, pharmacist and owner of Five Star, said the store's hours have been reduced to limit foot traffic, but the staff stays late to get prescriptions filled for the next day.
"The truth is we never close," Engelberg said. "We close the doors, but we don't close the work."
Engelberg, 49, focuses on filling prescriptions and limits sales of over-the-counter products to reduce the amount of time people spend in the store. Customers are so far remaining calm under the circumstances and are understanding of the new rules and restrictions, he said. Like most pharmacies, he faces shortages.
"One of the biggest problems is the supply chain has been rather dubious at times," Engelberg said. "I have a lot of wholesalers I deal with. It comes in, it comes out. You get them, you don't get them."
For the time being, Five Star has enough Z-paks in stock but there's no hydroxychloroquine. The unknown duration of the crisis weighs on Engelberg.
"With horrible situations like 9/11 and Hurricane Katrina and Sandy, you knew there was an end at some point — there was finality to it," Engelberg said. "This is something where we just don't know what's going to happen."