Personal protective equipment protecting healthcare workers in the Chinese epicentre of COVID-19

Abstract

Globally, healthcare workers (HCWs) have met an unprecedented challenge since the outbreak of coronavirus disease 2019 (COVID-19). HCWs made up 9.0% of the confirmed cases in Italy [[1]International Council of NursesHigh proportion of healthcare workers with COVID-19 in Italy is a Stark warning to the world: protecting nurses and their colleagues must be the number one priority.2020https://www.icn.ch/news/high-proportion-healthcare-workers-covid-19-italy-stark-warning-world-protecting-nurses-andDate accessed: March 20, 2020Google Scholar] and nearly 14.0% of the confirmed cases in Spain [[2]Minder R. Peltier E. Virus knocks thousands of health workers out of action in Europe. The New York Times, 2020https://www.nytimes.com/2020/03/24/world/europe/coronavirus-europe-covid-19.htmlDate accessed: March 24, 2020Google Scholar] in the first month of their respective outbreaks. Reasons for the rapid surge in HCW cases may in part be the lack of effective protection measures. Personal protective equipment (PPE) has been recommended for HCWs [[3]World Health OrganizationRational use of personal protective equipment (PPE) for coronavirus disease (COVID-19): interim Guidance.2020https://apps.who.int/iris/bitstream/handle/10665/331498/WHO-2019-nCoV-IPCPPE_use-2020.2-eng.pdfDate accessed: March 19, 2020Google Scholar] and it is important to evaluate its efficacy in protecting this vulnerable population while combating COVID-19. We conducted a cross-sectional survey (Supplementary Table S1) on PPE usage among 3476 HCWs who completed 14-day quarantine after their healthcare service for COVID-19 patients in Hubei province (the Chinese epicentre of the epidemic); the survey was carried out via the media platform Wechat between April 21 and May 15 2020. Our online questionnaire included (a) items selected from the WHO guidance for risk assessment and management of exposure of HCWs in the context of COVID-19 [[4]World Health OrganizationRisk assessment and management of exposure of health care workers in the context of COVID-19: interim Guidance.2020https://apps.who.int/iris/bitstream/handle/10665/331496/WHO-2019-nCov-HCW_risk_assessment-2020.2-eng.pdfDate accessed: March 19, 2020Google Scholar], (b) questions addressing the results of SARS-CoV-2-related tests (virus RNA and specific neutralizing antibody) before ending quarantine, and (c) PPE-related toxicities. To better track the use of PPE by HCWs, we stratified participants by HCW type (doctor, nurse, and others) and working area (three groups, detailed in Supplementary Material: Method), and scored the frequency of use of each type of PPE. More method details are provided in Supplementary Material: Method. Responses were obtained from a total of 960 HCWs who had provided healthcare service in over 37 Hubei hospitals (Supplementary Material Table S2). The response rate was 27.6%. Most participants were female (617, 64.3%), nurses (625, 65.1%), and HCWs assigned to work in Wuhan city (at least 856, 89.2%); the median age of the respondents was 33 (IQR 23–43) years. All participants were exposed to SARS-CoV-2 with a median period of 40 (IQR 16–64) days, and 926 (96.5%) of them cared directly for a confirmed COVID-19 patient. Before ending quarantine, all participants had three consecutive RT-PCR tests (7 days apart), and 672 (70.0%) were also tested for anti-SARS-CoV-2 IgG and IgM; 30.0% of the participants were not required to take this test, thus their results are unknown. All results were negative. Fig. 1 summarizes the frequency of use of each type of PPE in each HCW group, stratified by working area, and showed that there were no significant differences in the use of gloves or medical masks among the three groups; however, all other types of PPE were used most in group 1, and HCWs in group 2 (compared with those in group 3) used more N95/FFP2 respirators, face shields or goggles, and medical protective uniforms. PPE-related adverse events occurred in 838 participants (87.3%). The most common types were skin injury (598, 62.3%), dyspnoea (593, 61.8%), dizziness (555, 57.8%), and headache (516, 53.8%) (Table 1). Evidence from the comparison of HCWs with any adverse events versus those without any adverse events showed that older age (33 versus 31 median years, p 0.016) and more consecutive days using PPE (40 versus 35 median days, p 0.001) were associated with a greater risk of adverse events (Supplementary Table S3). HCWs had an increased risk of adverse events from group 3 (2.6%) to group 2 (34.7%) to group 1 (62.6%), with p < 0.05 between any two groups. Both doctors (30.2%) and nurses (66.5%) had greater risks of adverse events compared with other types of HCWs (3.3%, both p < 0.05).Table 1Characteristics and responses of 960 participantsCharacteristicNo. (%)Age, median (IQR), year33 (23.0–43.0)Sex, female617 (64.3)Type of healthcare worker: aMainly including medical doctor, physician assistant, radiology technician, ophthalmologist, physical therapist, respiratory therapist, midwife, psychotherapist, nutritionist, and physiotherapist.Doctor280 (29.2) bMainly including registered nurse, assistant nurse, and nurse technician.Nurse625 (65.1) cMainly including laboratory personnel, pharmacist, pharmacy technician or dispenser, administrator, admission/reception clerk, patient transporter, and cleaner.Others55 (5.7)Main working area: Fever outpatient department15 (1.6) General outpatient department or community12 (1.3) General patient room (non-intensive care unit)100 (10.4) Intensive care unit556 (57.9) Fangcang shelter hospital188 (19.6) Emergency department30 (3.1) Testing room9 (0.9) Cleaning area5 (0.5) Laboratory4 (0.4) Operating room4 (0.4) Imaging examination area4 (0.4) Others (pharmacy, administrative area, transfer vehicle, and others)33 (3.4)Providing direct care to a confirmed patient926 (96.5)dMainly including nebulizer treatment, open airway suctioning, collection of sputum, tracheotomy bronchoscopy, and cardiopulmonary resuscitation.Performing any aerosol-generating procedures on the patient577 (60.1)Accidental contact with body fluid/respiratory secretions of a confirmed patient Any72 (7.5) In the mucous membrane of eyes26 (2.7) In the mucous membrane of mouth/nose27 (2.8) On non-intact skin40 (4.2) Puncture/sharp accident with any material contaminated with biological fluid/respiratory secretions24 (2.5)Duration with PPE per day, median (IQR), hour6 (5.0–7.0)Consecutive days with PPE, median (IQR), day40 (16.0–64.0)Always or most of time adhere to PPE protocols as trained946 (98.6)Adverse event: Any838 (87.3) Skin squeeze598 (62.3) Dyspnoea593 (61.8) Dizziness555 (57.8) Headache516 (53.8) Rash222 (23.1) Dry skin199 (20.7) Allergy162 (16.9) Dermatitis146 (15.2) Maceration142 (14.8) Conjunctivitis61 (6.4) Stumble59 (6.1)Real-time RT-PCR test (three times): Negative960 (100.0) Positive0Anti-SARS-CoV-2 IgM test: Negative672 (70.0) Positive0Anti-SARS-CoV-2 IgG test: Negative672 (70.0) Positive0IQR, interquartile range; PPE, personal protective equipment; RT-PCR, reverse transcriptase–polymerase chain reaction.a Mainly including medical doctor, physician assistant, radiology technician, ophthalmologist, physical therapist, respiratory therapist, midwife, psychotherapist, nutritionist, and physiotherapist.b Mainly including registered nurse, assistant nurse, and nurse technician.c Mainly including laboratory personnel, pharmacist, pharmacy technician or dispenser, administrator, admission/reception clerk, patient transporter, and cleaner.d Mainly including nebulizer treatment, open airway suctioning, collection of sputum, tracheotomy bronchoscopy, and cardiopulmonary resuscitation. Open table in a new tab IQR, interquartile range; PPE, personal protective equipment; RT-PCR, reverse transcriptase–polymerase chain reaction. The present study focuses on the efficacy and safety of PPE for HCWs in the Chinese epicentre of COVID-19, which we believe is critical to establishing appropriate responses to this and future epidemics. First, the negative results of RT-PCR tests in all participants with a median 40-day exposure duration—along with negative results of antibody tests in 70.0% of participants showing that they were never infected—indicated that PPE is an efficacious measure to durably contain the nosocomial transmission of SARS-CoV-2. Second, the efficacy of different PPE among HCWs in different working areas supports the need for guidance on rationalizing, prioritizing, and grading the use of PPE according to HCWs' infection risk. This information can also address the critical shortages of PPE, allowing appropriate allocation of PPE. Third, basic emergency guidance or directive of PPE for protecting HCWs should be issued at the earliest stage of an epidemic, not months later. Furthermore, the need for emergency stocks of PPE has been highlighted to avoid the dire consequences of PPE shortages. Fourth, PPE was commonly associated with adverse events in our participants, although 98.6% of them showed high levels of adherence to PPE protocols. These effects are mild in most cases but can affect HCWs both physically and psychologically. The need for improvements in PPE design is highlighted, especially with HCWs' participation and contributions. YZ, WL, YL, YC, PL and RZ all contributed equally to this article as joint first authors. JH and AC supervised the overall study. JH, AC and YZ contributed to the study concept and design. WL and YC collected the data. YZ, YL and RZ analysed and interpreted the data. PL produced the figure and tables. YZ, YL and AC wrote the manuscript, and all authors approved its final version. The authors declare no competing interests. This study was supported by the National Natural Science Foundation of China (grant number 81903421). The institutional review board at The First Affiliated Hospital of Guangzhou Medical University approved this study, and informed consent was obtained from all participants. The following is the Supplementary data to this article: Download .docx (.03 MB) Help with docx files Multimedia component 1 Re: 'Personal protective equipment protecting healthcare workers in the Chinese epicenter of COVID-19' by Zhao et al.Clinical Microbiology and InfectionVol. 26Issue 12PreviewWe read with interest the article by Zhao et al. describing personal protective-equipment (PPE) usage among different groups of health-care workers (HCWs) during the coronavirus disease 2019 (COVID-19) epidemic in Wuhan [1]. However, ancillary HCWs (excluding doctors and nurses) formed a minority (5.7%, 55/960) of the HCWs surveyed [1]. Emphasis has been placed on clinical staff as being at-risk HCWs. However, ancillary HCWs, such as cleaning staff and security officers, also have substantial risk for work-related transmission of COVID-19 [2]. Full-Text PDF Open Archive