The supply of personal protective equipment (PPE) is inadequate throughout the US and the world. This is especially true of N95 respirators. The cost of PPE is high. There are numerous cases of health care workers (HCW) working with inadequate PPE and being disciplined on complaining. In the US, thousands of HCW have contracted COVID-19, in part due to inadequate PPE. Extended use and reuse of N95 respirators has been permitted by CDC. The N95 respirators can be sterilized utilizing vaporized hydrogen peroxide, ultraviolet germicidal irradiation, or dry heat at 70-80 °C.
The risk to HCW due to inadequate PPE increases with their age and presence of comorbidities. African Americans and Latinos are at a greater risk. CDC recommends that in the absence of appropriate PPE, “exclude healthcare personnel at higher risk for severe illness from COVID-19 from contact with known or suspected COVID-19 patients.” Providing care without appropriate PPE should not be a condition of employment for any clinician, especially for the ones in high risk category.
Introduction & Background
SARS-CoV-2 is a very infective virus. Health care workers (HCW) caring for COVID-19 patients or persons under investigation (PUI) are at a greater risk of contracting the illness than the general population. In the US, thousands of HCW including anesthesiologists have contracted COVID-19.
The risk of morbidity and mortality increases with age and presence of comorbidities. The risk is greater among people of color, African Americans and Latinos. Appropriate utilization of personal protective equipment (PPE) can mitigate the risk. However, there is a shortage of PPE, especially N95 respirators. CDC has approved extended use, reuse, and reprocessing of N95 respirators. HCW must ensure that they follow guidelines including handwashing and appropriate use of PPE.
Personal Protective Equipment
For protection against COVID-19, personal protective equipment (PPE) include head, face, beard, and shoe covers; impervious gown, gloves, respirator, and eye protection. According to the Anesthesia Patient Safety Foundation (APSF), anesthesiologists should utilize appropriate PPE for all patients during airway management . The American Society of Anesthesiologists (ASA) and other organizations have recommended “all anesthesia professionals should utilize PPE appropriate for aerosol-generating procedures for all patients when working near the airway .”
HCW Contracting COVID-19
HCW including anesthesiologists are at a substantial risk for contracting and spreading COVID-19 . According to the Morbidity and Mortality Weekly Report (MMWR) dated 04/14/20 by the Centers for Disease Control and Prevention (CDC), 9,282 US HCW contracted COVID-19 . Ninety percent of them were not hospitalized. About 0.5% expired. Limited data indicated that HCW accounted for about 11% of all COVID-19 infections, although they are a much lower percentage of population. According to unpublished accounts, as of 04/23/20, more than 21,800 US HCW had contracted COVID-19 and 71 had died.
This very high risk causes psychological distress among HCW . It is especially so among younger and more junior people and those with dependent children . Risk factors for HCW contracting COVID-19 include inadequate handwashing, inadequate or improper use of PPE, and prolonged work hours and exposure . Infected HCW are vectors for infection. In Wuhan 41% of the Covid-19 cases resulted from hospital-related transmission .
Shortage of PPE
The supply of PPE is inadequate throughout the US and the rest of the world [8-11]. This is especially true of N95 respirators and surgical masks. In some locations, the shortage is critical, forcing HCW to work under unsafe conditions. In part because of the shortage, the cost of PPE is high which makes it difficult for many hospitals and other health care institutions to pay for PPE.
US manufacturers are increasing the production of PPE. Attempts are being made to import more PPE. N95 respirators approved by the National Institute for Occupational Safety and Health (NIOSH) but not the US Food and Drug Administration (FDA), and intended for industrial use, are being allowed to be used for medical applications. Activation of the Defense Production Act has allowed the government to direct industry to switch to producing PPE. PPE are also being released from the limited supply at the Strategic National Stockpile.
Some of the stockpiled N95 respirators are expired. The elastic band of an expired respirator may not function well. If the band is serviceable, an expired respirator may be usable. Many people are using home-made masks or bandanas that are appropriate for the general public but not for the HCW, although the CDC has recommend using bandanas if surgical masks are not available .
Physicians and Nurses Disciplined for Complaining
Throughout the US there are numerous cases of physicians and nurses working with inadequate PPE and being disciplined if they complain, especially if those complaints are to social or other forms of media [13-15]. According to the New York Times, every major private hospital system and some public hospitals in New York City have sent memos ordering workers not to speak to the media.
There are many disputes between clinicians and hospitals regarding what PPE is required in various settings. Many hospitals are requiring HCW to reuse their own PPE. Some hospitals that do not provide adequate PPE still restrict the PPE that HCW can bring to the hospital.
Extended Use and Reuse of N95 Respirators
In the past, PPE was to be discarded after every patient encounter. During the current shortages, the CDC recommends a maximum period of 8-12 hours of extended use for multiple patients without doffing. CDC suggests limiting N95 respirator reuse to no more than five times per device with doffing between uses. A face shield or surgical mask can be utilized to cover the N95 respirator for extended use or reuse.
Reprocessed N95 Respirators
During shortages, the respirators can be sterilized [16,17]. Apparatus utilizing vaporized hydrogen peroxide is widely available in hospitals [18,19]. This can allow decontamination of up to four million N95 respirators and is being widely used in many institutions. After 20 cycles of sterilization, the filtration of the masks was not impaired, but the mask fit was degraded. Filtration was not impaired after up to 50 cycles of ultraviolet germicidal irradiation, but the fit was impaired after an average of 3 cycles. Dry Heat at 70-80 °C can be used for two cycles of decontamination. Reprocessed N95 respirators should be checked for fit and function.
Novel and creative solutions have been proposed to provide protection in the absence of N95 respirators. These include securing an anesthesia breathing circuit mask on the face of the clinician [20,21]. A HEPA filter can be placed between the mask and the atmosphere. A respirator fashioned from a snorkel mask has received FDA approval. The efficacy of a surgical mask or bandana can be
increased by making it fit tightly. This can be achieved by utilizing tape, elastic bands, and other items. More efficient masks may be available in near future [22,23].
Risk of COVID-19 in US
The MMWR dated March 31, 2020 reported data on COVID-19 patients in the US . Among patients aged ≥19 years of age, 37.6% of the patients had at least one of the following underlying medical conditions:
- diabetes mellitus (10.9%),
- chronic lung disease (9.2%),
- cardiovascular disease (9.0%),
- chronic renal disease, chronic liver disease, immunocompromise, neurologic disease, neurodevelopmental or intellectual disability, pregnancy, smoking, or other chronic disease including cancer and hypertension.
The percentage of such patients among all patients not requiring hospitalization was 27%, among all patients requiring hospitalization without intensive care unit (ICU) admission was 71%, among all patients requiring ICU admission was 78%, and among all expired patients was 94%. Stratification by the number, severity, and level of control of underlying medical conditions is not available.
Table 1 stratifies the risk by age and underlying medical condition. Thus, 22.2% of the patients older than 65 years and with one or more underlying medical conditions were admitted to ICU. Only 2% of the patients younger than 65 years and with no underlying medical condition were admitted to ICU. Older age and an underlying medical condition, each increased the risk about three-fold. Together, they increased the risk by an order of magnitude.
Risk of COVID-19 in Other Countries
A study of patients from China and 37 other countries estimated a mortality of 13.4% in patients 80 years and older, 8.6% in patients 70-79 years old, 4% in patients 60-69 years old, 1.25% in those 50-59 years old and 0.3% in those 40- 49 years old . A study of Italian patients estimated a mortality of 20.2% in patients 80 years and older, 12.8% in patients 70-79 years old, 3.5% in patients 60-69 years old, 1% in those 50-59 years old and 0.4% in those 40-49 years old .
Although detailed data are not yet available, African Americans, Latinos, and other minorities are at a greater risk of contracting COVID-19 [27,28]. If they develop COVID-19, they have a greater risk of mortality. One reason for this is that they have higher rates of comorbidities including hypertension, heart disease, diabetes, and lung disease. According to US Surgeon General Jerome M. Adams, “the burden of social ills is also contributing.” For a myriad of reasons, minorities and people of color are more likely to get inadequate care and to get care later in the disease cycle. More African Americans, Latinos, and other minorities have jobs that require person to person interaction, precluding teleworking or working from home. Many work in service, transportation and hospitality industries. Many such jobs are considered “essential,” which prevents them from staying home safely. The US Surgeon General Adams said, “People of color are more likely to live in densely packed areas and in multi- generational housing situations, which create higher risk for spread of highly contagious disease like covid-19.”
Other Risk Factors
In US, COVID-19 has infected more women but killed more men . In China, mortality was much higher among men. The cause for this is not elucidated. Since the virus can gain entry from a break in the skin, a HCW with injury or recent surgery may be at increased risk . Patients with blood type A may be at a higher risk of infection and develop more severe symptoms whereas patients with blood type O may be at a lower risk [31,32].
Mitigating Risk for HCW’s Families
Although some HCW have chosen to live apart from their families, it is recommended that HCW continue to stay at home with their families [33-35]. This preserves everyone’s mental health. HCW should carefully follow standard precautions including utilization of appropriate PPE at work and washing hands as indicated. On arriving home they may change clothes and shower. They may avoid sharing utensils and items of personal use. They should maintain social distance from their family members as necessary, especially if the family members are in the high-risk category.
HCW at Risk
Regardless of the degree of symptoms or acuity of illness, substantial environmental contamination is present in air samples and surface samples from the room where a COVID-19 patient is cared for . Infectious aerosol is present even in the absence of procedures known to generate aerosol. It is known that asymptomatic and pre-symptomatic carriers can transmit SARS-CoV-2 virus . Nebulization and non-invasive positive pressure ventilation also generate large amounts of aerosol.
Even though not necessarily at increased risk, pregnant HCW do not want any health issues to affect them or their infants. Some HCW are sole breadwinners with small children or other dependents . Some HCW may have mental health issues.
Risk With Inadequate PPE
Although physicians who themselves are in high risk categories are safe when utilizing appropriate PPE, in its absence they are at substantial risk. The CDC recommends that in the absence of appropriate PPE, institutions should “exclude healthcare personnel at higher risk for severe illness from COVID-19 from contact with known or suspected COVID-19 patients .” Providing care without appropriate PPE should not be a condition of employment for anyone, especially for people in high risk category. The argument that individuals who chose careers in healthcare accepted its potential risks is disingenuous and does not apply.
Providing Care Despite Inadequate PPE
Many HCW work in settings where they consider the PPE to be inadequate. One approach to providing care in this setting is to incentivize call and make it voluntary. Anesthesia professionals who agree to provide call coverage also agree to care for COVID-19 patients. Those who forego call are not required to care for patients who have tested positive for SARS-CoV-2 and for persons under investigation. This also preserves PPE and facilitates acquisition of greater experience by the on-call group.
Utilizing appropriate PPE is the key to safely providing care for COVID-19 patients. There is a
worldwide shortage of PPE. To alleviate it, CDC is allowing extended use, reuse, and reprocessing of N95 respirators. HCW are at increased risk and thousands of HCW in the US have been
infected with COVID-19. This is in part due to inadequate utilization of PPE. Risk of infection
increases with age and presence of comorbidities. African Americans and Latinos are at increased risk. It is recommended that HCW do not stay away from their families but instead follow all precautions. HCW should not be required to provide care in the absence of adequate PPE. This is especially true of HCW in high risk categories.
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