Complete protection from covid-19 is possible for health workersBMJ 2020; 370 doi: https://doi.org/10.1136/bmj.m2641 (Published 07 July 2020) Cite this as: BMJ 2020;370:m2641
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My team and I have thoroughly read the editorial published by Karlsson and colleagues.  It raises pressing issues in the current pandemic scenario, where the disease burden has negatively affected healthcare budgets, healthcare delivery, and raised the overall global economic burden. With the rapid increase in the number of COVID-19 cases in Pakistan, it remains vital that frontline healthcare workers should be provided with adequate personal protective equipment (PPE). We agree with the main theme of the editorial which emphasizes that providing adequate PPE and training helps alleviate the chances of infections in healthcare workers.  However, to assume based on a few studies that providing PPE to healthcare workers ensures no chance of infection is presumably incorrect. Despite adequate PPE availability and training, it is still possible that many healthcare workers will contract COVID-19. Even though adequate PPE materials are provided to healthcare personnel, many other factors must be considered when analyzing the reduction of infection risk in healthcare personnel. We believe that the quality of PPE training and PPE materials must also be taken in to account.
Agreeing with the main notion that PPE is a vital requirement which the hospital administrations and governments must procure for their frontline healthcare workers, Pakistan has failed to provide their healthcare workers with this basic safety necessity. As per a study conducted by Ahmed et al., only 37.4% of doctors in Pakistan have access to masks/ N95 respirators.  Furthermore, only 34.5% have access to gloves, 13.8% to face-shields or googles, and 12.9% to full suit/gowns.  It has also been noted that 60.3% of physicians have had to reuse PPE.  Alarmingly, 50.6% of physicians in Pakistan have been forced to work without PPE.  The above data paints a bleak picture of the essential safety of healthcare workers across Pakistan. This has caused unrest at the administrative, social, and political levels. As a consequence, there has been a sharp rise in the number of COVID-19 infections in healthcare workers. As of July 10, the number of infected healthcare workers has risen to 6025.  More specifically, the majority of healthcare workers who tested positive belong to Khyber Pakhtunkhwa (1986 cases), Sindh (1752 cases), and Punjab (1100 cases).  The estimated mortality has been recorded at 69 healthcare workers.  The majority of the healthcare workers have died in Sindh. 
We believe the current government and various administrations have not taken the task of healthcare personnel safety seriously. We believe the shortage of PPE has occurred due to multiple reasons. One of the many reasons accounting for the shortage of PPE seems to be discrimination. There have been multiple reports suggesting that a lack of seniority in position is contributing to this shortage and putting junior medical officers at risk. It is also possible that the biased distribution of resources has also occurred based on a political agenda. The fear of uncertainty among the population has resulted in panic buy and hoarding of PPE supplies. As a consequence, the manufacturing divisions have had immense trouble in trying to keep up with supply production. Despite the efforts of various NGOs in Pakistan, the protection of Pakistani healthcare workers is nowhere near international standards.
Overall, physicians in Pakistan fear that they might transmit this infection to their loved ones. The inept policies and inadequate PPE availability are slowly starting to damage the healthcare sector in Pakistan. It has been reported that 46% of Pakistani physicians are likely to quit their job due to a lack of PPE.  We recommend that the general public must be educated about the importance of PPE for healthcare workers. There must be a supervised system in place for the distribution of PPE amongst healthcare care workers. The issue of lack of PPE availability for all physicians must be raised on all international forums worldwide. This is because increased rates of infection in healthcare personnel can eventually reduce the healthcare workforce and effectively cripple the healthcare system.
1. Karlsson Ulf, Fraenkel Carl-Johan. Complete protection from COVID-19 is possible for health workers BMJ 2020; 370:m2641
2. Ahmed J, Malik F, Bin Arif T, et al. (June 10, 2020) Availability of Personal Protective Equipment (PPE) Among US and Pakistani Doctors in COVID-19 Pandemic. Cureus 12(6): e8550. doi:10.7759/cureus.8550
Competing interests: No competing interests
The editorial on complete protection for healthcare workers (HCW) resonated with Liu and colleagues’ study and re-emphasized the effectiveness of appropriate personal protective equipment (PPE) on protecting frontline healthcare workers during the SARS-CoV-2 epidemic. We applaud the authors’ well-articulated arguments on defining the “appropriateness” of PPE based on evidence rather than irrational fears; yet, as we learned from the local experience in Hong Kong, especially those from the SARS-CoV-1 outbreak, appropriate PPE is only one of the few factors that could help protect HCWs.
In the immediate aftermath of the SARS-CoV-1 epidemic, the Hong Kong government commissioned an independent, cross-disciplinary expert review of the epidemic response. [1,2] Five major risk factors for HCWs post SARS were identified: (i) lack of training in infection control; (ii) inadequate supply and use of personal protective equipment (PPE); (iii) lack of infection control facilities (e.g. Isolation ward with negative pressure); (iv) increased workload, stress, and strain on the healthcare staff and system; and (v) the use of nebulizers that produces virus-rich aerosols. This review led to system-wide changes and significant improvements in the infection control and outbreak preparedness in Hong Kong’s public healthcare system. [1-3]
Seventeen years later, most of the five factors have been tackled in Hong Kong, but new issues have also emerged. The proportion of HCW COVID-19 cases among all cases ranges from as high as 16.6% in Philippines, 14% in Spain, 11% in Italy to as low as 1.2% in Indonesia or 1.7% in China (excluding Hubei).  Hong Kong so far has had only 2 cases in HCW up to 13 July among the total 1470 infections. One case was a 54-year-old female doctor who was tasked with issuing quarantine orders to visitors at Hong Kong International Airport in March ; the other was a 27-year-old paramedic who transported a woman diagnosed with COVID-19 from her home to hospital in June.  In both cases, the two HCWs wore surgical masks only.
These two infections remind us that the frontline of the SARS-CoV-2 has been expanded from hospitals to elsewhere, be it private clinic, airport, patients’ homes, or any public areas where the HCWs are needed. Different to SARS-CoV-1, this novel coronavirus can be transmitted from people without symptoms to others. As WHO admitted on 9 July, asymptomatic transmission and pre-symptomatic transmission are two distinctive features of SARS-CoV-2 in its newly updated guidelines.  Moreover, in the same guidelines, WHO also admitted airborne transmission of COVID-19 “cannot be ruled out” in in-door places.  Hence, it would be extremely difficult for HCWs to find an “appropriate” moment to be fully geared with PPE. Their frontline is everywhere.
So, the question is, once again, how do we define the “appropriateness” of PPE protection for HCWs? If the battle against COVID-19 continues, the definition should not just be derived from evidence, but also based on the views and perspectives of frontline HCWs as well. As the battle continues, in addition to the prolonged shortage of PPE, many HCWs may also suffer from the moral injury  that might affect their compliance with PPE requirement. More efficient and innovative ways of protecting HCWs, such as using AI robotics as substitutes under certain highly risky environment and timely psychological and emotional support for HCWs, need to be taken seriously.
Eliza Lai-Yi Wong, Dong Dong, Sian Griffiths, SF Lui, CT Hung, Hong Fung, EYY Chan, Eng-Kiong Yeoh
1. SARS Expert Committee. SARS in Hong Kong: From Experience to Action. [Hong Kong]: [Government Logistics Dept.]; 2003.
2. Hong Kong Hospital Authority. Report of the Hospital Authority Review Panel on the SARS Outbreak; 2003.
3. Naylor CD, Chantler C, Griffiths S. Learning from SARS in Hong Kong and Toronto. JAMA. 2004;291(20):2483-2487. doi:10.1001/jama.291.20.2483.
4. COVID-19 Scientific Advisory Group. COVID-19 Scientific Advisory Group Rapid Response Report: COVID-19 Risk to Healthcare Workers; May 2020. https://www.albertahealthservices.ca/assets/info/ppih/if-ppih-covid-19-h....
5. Siu P. Coronavirus: Hong Kong doctor who monitored travellers at airport among 39 new Covid-19 cases. South China Morning Post. March 23, 2020. https://www.scmp.com/news/hong-kong/health-environment/article/3076375/c.... Accessed July 13, 2020.
6. Cheung E. Coronavirus: Hong Kong records four new preliminary positive cases, after earlier confirming three locally. South China Morning Post. June 1, 2020. https://www.scmp.com/news/hong-kong/health-environment/article/3086933/c.... Accessed July 13, 2020.
7. Transmission of SARS-CoV-2: implications for infection prevention precautions. https://www.who.int/news-room/commentaries/detail/transmission-of-sars-c.... Updated July 10, 2020. Accessed July 13, 2020.
8. Greenberg N, Docherty M, Gnanapragasam S, Wessely S. Managing mental health challenges faced by healthcare workers during covid-19 pandemic. BMJ. 2020;368:m1211. doi:10.1136/bmj.m1211.
Competing interests: No competing interests
The authors cite in detail the Chinese studies showing lack of transmission to HCWs with adequate PPE in China and then conclude that the surgical mask advice from the WHO is entirely adequate. However, PPE standards in China are far higher than the WHO recommendations, encompassing N95 masks for all COVID patients and full body suits:
They are not comparing like with like.
Infection control for HCWs should be based on a precautionary principe and not a minimalist one. The safety culture in medicine is unacceptably weak and this editorial does nothing to strengthen it.
Competing interests: No competing interests