Re: Use of personal protective equipment against coronavirus disease 2019 by healthcare professionals in Wuhan, China: cross sectional study
It was a pleasure for us to read the article titled ‘Use of personal protective equipment against coronavirus disease 2019 by healthcare professionals in Wuhan, China: cross sectional study’ by Liu et al. ,in your esteemed journal. It is a well-written article, and we commend the authors on their remarkable effort. It is a particular topic of interest for us and we feel we could add a few important points here which would enrich the paper further.
A study by Ong et al.  found that most healthcare workers develop de novo PPE-associated headaches or exacerbation of their pre-existing head ache disorders. Pain or discomfort is often experienced from tight-fitting PPE, after prolonged use. The designs of PPE rely on elastic head straps to ensure a tight-fit, often causing headache, facial pain, and ear lobe discomfort due to tractional and tensional forces to the head. Doctors and nurses working in high risk hospital areas, especially at the emergency department have a greater risk of such headaches. The headache frequency, severity, use of analgesics, and work performance may worsen if the current COVID-19 outbreak is prolonged for a much longer time. In addition, the PPE leads to thermal discomfort, causing a build-up of moist warm air inside the mask and goggles. The conventional N95 face mask and protective eyewear fit tests consider only the overall fit factor and do not take into account the level of comfort or tolerability especially when used for prolonged periods of time. The magnitude of this condition is clinically significant and might worsen if the current outbreak spreads widely and stays for a longer time, affecting the work performance of healthcare workers. Perhaps, better strategies are needed for designing more ergonomic personal protection equipment and reducing their exposure time by healthcare workers.
Prolonged use of PPEs may also lead to a rise in dermatological problems by healthcare workers, as seen in a study by Foo et al, in which the most common adverse reaction reported to the N95 mask was allergic skin diseases. Pilosebaceous duct occlusion as a result of local pressure on the skin from the close-fitting mask could result in a flare-up of acne. True allergic contact dermatitis may occur due to adhesives used in the masks or to mask components such as rubber straps or metal clips.
Another important factor that to be taken into consideration is the limitation in PPE availability . The shortage of PPE combined with unclear and changing guidance has resulted in anxiety and confusion for healthcare workers. The use of scientific evidence and principles such as social worth, reciprocity and protection of the vulnerable healthcare, provides a useful framework for making difficult rationing decisions regarding PPE. The current global stockpile of PPE is inadequate to meet not only the current need but also future escalating demand.  An examination of the extended use and reuse of respirators found that reuse of respirators could be feasible for non-contact transmission. This was a result of the extended use of masks resulting in comfort issues, which would cause additional touching of the mask, increasing the possibility of infection. Extended use could also allow for degradation of elements such as straps. As a result, the chance of transmission of the disease while reusing and decontaminating the PPE should be taken into consideration. 
1. Liu M, Cheng S-Z, Xu K-W, Yang Y, Zhu Q-T, Zhang H, et al. Use of personal protective equipment against coronavirus disease 2019 by healthcare professionals in Wuhan, China: cross sectional study. BMJ 2020;369:m2195 http://dx.doi.org/10.1136/bmj.m2195.
2. Ong JJY, Bharatendu C, Goh Y, Tang JZY, Sooi KWX, Tan YL, et al. Headaches associated with personal protective equipment – a cross-sectional study among frontline healthcare workers during COVID -19. Headache 2020;60:864-877.
3. Foo CCI, Goon ATJ, LeowY-H, Goh C-L. Adverse skin reactions to personal protective equipment against severe acute respiratory syndrome – a descriptive study in Singapore. Contact Derm 2006:55:291–294.
4. Jessop ZM, Dobbs TD, Ali SR, Combellack E, Clancy R, Ibrahim N, et al. Personal protective equipment for surgeons during COVID-19 pandemic: systematic review of availability, usage and rationing, BJS 2020;107:1262–1280.
5. O’Dowd K, Nair KM, Forouzandeh P, Mathew S, Grant J, Moran R, et al. Face Masks and Respirators in the Fight Against the COVID-19 Pandemic: A Review of Current Materials. Advances and Future Perspectives. Materials 2020;13:3363. doi:10.3390/ma13153363.
Competing interests: No competing interests