Covid-19: Exposing frontline NHS staff to dangers by asking them to reuse PPEBMJ 2020; 369 doi: https://doi.org/10.1136/bmj.m1911 (Published 14 May 2020) Cite this as: BMJ 2020;369:m1911
All rapid responses
Professor Hadi refers to research conducted by Health and Safety Executive (HSE) scientists in collaboration with Sheffield Teaching Hospitals staff and on behalf of the High Consequence Infectious Diseases (HCID) network of hospitals. The outcome of this work was published in three papers in 2018(1,2,3) and further summarised in an HSE research report issued in 2020(4). Professor Hadi uses these data to highlight potential problems with PPE use in the current COVID-19 pandemic situation, including suggesting that the NHS is advising staff to reuse PPE. Although he summarises the outcome of the research(2) well, he does so out of context. The work was done using a manikin adapted to expose volunteer healthcare workers (HCW) to body fluid surrogates with different coloured fluorescent markers. It was however designed, following the Ebolavirus outbreak in 2014-15, to mimic care of patients with HCID such as viral haemorrhagic fevers where large volume exposure to vomit and diarrhoea may be anticipated. Different PPE ensembles were tested, and this led to the development of a unified PPE ensemble for use with HCID, also including protection against airborne transmissible agents such as monkeypox which is highly infective in low viral numbers(3).
Although initially COVID-19 was provisionally classified in January 2020 as HCID(5) as an interim measure, by 19th March 2020 the 'Four Nations' Public Health Group, supported by the UK Advisory Committee on Dangerous Pathogens, concluded that SARS-CoV-2 should no longer be classified as an HCID agent. This was based on factors that apply to HCID such as high case-fatality rate, low likelihood of developing effective prophylaxis or treatment, and difficulties in recognising and detecting the agent rapidly, none of which applies to SARS-CoV-2.
Care of COVID-19 patients typically is done in intensive care wards but outside the HCID hospital setting. This is based on clinical evidence that caring for COVID-19 patients is not likely to expose HCW to large volumes of infective body fluid. NHS and PHE, in their infection prevention and control guidance(6), describe a range of COVID-19 patient care clinical scenarios and the appropriate PPE ensembles proportionate to providing HCW protection. These were developed in wide consultation, including with HSE. The guidance also provides links to videos and written guidance on safe doffing of potentially contaminated PPE.
Professor Hadi also refers to advice from NHS to reuse PPE. In the work on HCID PPE ensembles, the only PPE deemed fit for validated decontamination and re-use was wellington boots. Studies are underway in the UK, as they are in other countries(7) to determine whether some PPE components used in the treatment of Covid-19 patients could be decontaminated and reused in an emergency supply situation. However this would only be advocated in strictly defined circumstances, supported by robust evidence that decontamination had been validated and proven to be effective, and also that the PPE remained sufficiently protective and created no additional risk to health.
Samantha Hall*, Bozena Poller**, Brian Crook*
*Health and Safety Executive, Science and Research Centre, Buxton SK17 9JN, UK
**Locum Consultant in Medical Virology, Sheffield Teaching Hospitals, Sheffield S5 7AU, UK
Competing interests: none declared.
The work described in this letter was funded by HSE and NHS. However the contents of this letter, including any opinions and/or conclusions expressed, are those of the authors alone and do not necessarily reflect HSE or NHS policy.
1. Poller B, Hall S, Bailey C, Gregory S, Clark R, Roberts P, Tunbridge A, Poran V, Crook B, Evans C. “VIOLET” – a fluorescence-based simulation exercise for training healthcare workers in the use of personal protective equipment. J Hosp Infect 2018; 99: 229-235. Doi: 10.1016/j.jhin.2018.01.021.
2. Hall S, Poller B, Bailey C, Gregory S, Clark R, Roberts P, Tunbridge A, Poran V, Evans C, Crook B. Use of ultraviolet-fluorescence-based simulation in evaluation of personal protective equipment worn for first assessment and care of a patient with suspected high-consequence infectious disease. J Hosp Infect 2018; 99: 218-228. Doi: 10.1016/j.jhin.2018.01.002.
3. Poller B, Tunbridge A, Hall S, Beadsworth M, Jacobs M, Peters E, Schmid ML, Sykes A, Poran V, Gent N, Evans C, Crook B on behalf of the High Consequence Infectious Diseases Project Working Group. A unified personal protective equipment ensemble for clinical response to possible high consequence infectious diseases: A consensus document on behalf of Public Health England and the Health and Safety Executive. Journal of Infection, 2018; 77: 496–502 https://doi.org/10.1016/j.jinf.2018.08.016
4. Health and Safety Executive England. Evaluation of existing PPE worn by NHS staff for assessment of a patient with a suspected high consequence infectious disease. Report No RR1147. 2018. www.hse.gov.uk/research/rrpdf/rr1147.pdf .
6. COVID-19: infection prevention and control guidance https://www.gov.uk/government/publications/wuhan-novel-coronavirus-infec...
7. Juang PSC, Tsai P. N95 Respirator cleaning and re-use methods proposed by the inventor of the N95 mask. Journal of Emergency Medicine https://doi.org/10.1016/j.jemermed.2020.04.036 2020 (in press)
Competing interests: No competing interests
Sudden rise of Covid-19 infection among health care providers (HCPs) in Pakistan; 40% increase in one week.
According to the ministry of health government of Pakistan, up till now, 1292 HCPs have been infected with Covid-19 and 12 persons lost their lives during the battle with this virus. But the most alarming issue is that only in the last week 509 people are newly diagnosed--that is, around 40% of total infection. Among them 661 are the doctors, 210 are nursing staff and 749 are the paramedics.
HCPs are the front-line workers against the fight with Covid-19, when they got infection then the 1st thing that come in the mind is personal protective equipment (PPEs). As already discussed, by Sibte Hadi (https://www.bmj.com/content/369/bmj.m1434/rr-18) and Kamran Abbasi (https://www.bmj.com/content/369/bmj.m1434) that substandard PPEs played a role in spread of infection among the HCPs. Even that, it was found in the UK that PPEs were inefficient to protect the staff from infection. The situation in Pakistan is much worse because we relied on the imported stuff form China and there were no quality control protocols designed to ensure the quality. Moreover, the shortage of time and emergency forced the government officials to distribute as received. Additionally, there are a few more factors that worsened the situation more abruptly:
1. Inadequate supply of PPEs to HCPs in both the secondary and tertiary care units.
2. No protocols designed to control quality control of PPEs; thus, substandard equipment is provided.
3. There is no proper replenishment of the supply. So, HCPs are forced to reuse although knowing that in this way they are more prone to infection.
4. The cost of PPEs increased a lot, no effective measures to control it, N95 mask price in country was 95 PKR; 0.60 USD before endemic now raised to 1500 PKR; 9.3 USD. Same is the situation with gloves, face shields, etc.
5. There is also lack of training regarding donning and doffing processes.
In conclusion, this is the responsibility of the ministry of health, government of Pakistan to implement corrective measure to assure the quality standards for PPEs import and as well as its manufacturing inside the country. There should be adequate supply and must be control mechanism to control the pricing if someone wants to buy it personally and proper training how to use PPEs.
Competing interests: No competing interests