COVID-19 Pandemic: Is Sustainability the Answer to Personal Protective Equipment (PPE) Shortages?

by Vivian Ip MB ChB FRCA†, Timur Özelsel MD DESA†, Rakesh Sondekoppam MBBS MD‡, Ban Tsui MD MSc FRCPC

†Associate Clinical Professor, University of Alberta Hospital, Department of Anesthesia and Pain Medicine, Edmonton, Alberta. Canada. ‡Associate Professor, Department of Anesthesia, University of Iowa Hospital, Iowa City, Iowa. ?Professor, Stanford University School of Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Palo Alto. CA.

 

Background

Clusters of atypical pneumonia of unknown origin were first described in Wuhan, China in December 2019, which was later found to be caused by a novel coronavirus transmitted to humans from exotic animals.[1] However, the scale of the devastation was not realized until the mortality rate increased exponentially over a period of days in mainland China. This novel agent resulted in the institution of an unprecedented and strict “lock-down” of social and industrial activities. The rest of the world watched, and neighbouring countries to China began to prepare for another epidemic, similar to Severe Acute Respiratory Syndrome caused by coronavirus in 2003 (SARS-CoV-1). The explosive outbreak of the SARS-CoV-1 pandemic was curtailed in Asian countries following drastic measures including the closure of borders. Relative to SARS-CoV-1, the coronavirus disease that emerged in 2019 (COVID-19) is more contagious; therefore, the absolute death toll has been higher despite its presumed lower mortality rate. The medical system in the epicentre, Wuhan, was quickly overwhelmed with the need to ration PPE in anticipation of potential shortages. PPE shortages ultimately created a situation where medical personnel were unable to take breaks for water, food or bathroom during an eight-hour shift as hospitals attempted to preserve employee hazmat suits. [2]


With the current pandemic of unknown duration, sustainability will ensure HCPs protection while reducing the environmental burden.


COVID-19 is associated with a spectrum of disease presentations, ranging from mild influenza-like-symptoms to respiratory failure requiring mechanical ventilation. The possibility of asymptomatic transmission based on several case reports as well as the rapid transmission rate in nursing homes [3],[4],[5] has led to a further increase in the use of PPE and has resulted in a further draining of resources. With globalization, especially when the initial outbreak coincided with the Lunar New Year where millions of people traveled nationally and internationally, COVID-19 has rapidly spread across the globe, leading the World Health Organization (WHO) to declare a global pandemic on March 11, 2020. The first confirmed COVID-19 case in the USA was on January 20, 2020, and 3 months later, the number has exploded to more than a million.

Global shortages of personal protective equipment (PPE)

On March 3, 2020, the WHO warned against severe and mounting disruptions to the global supply of PPE, caused by rising demand, panic buying, hoarding, and misuse.[6] Without appropriate PPE, healthcare providers (HCPs) working on the frontline are risk acquiring nosocomial infections and infecting others. The WHO calls on industry and governments to increase manufacturing by 40% to meet rising global demand. [6] Based on WHO modelling, an estimated 89 million medical masks are required for the COVID-19 response each month. For examination gloves, that figure is 76 million, while international demand for goggles stands at 1.6 million per month. [6] While the presumed mode of transmission is contact and droplet, barrier precautions such as gowns, gloves, surgical masks, and eye protection are recommended. However, in a hospital setting where the global recommendation of social distancing is usually impossible, continuous masking by patients and medical personnel has recently been recommended in the western hemisphere for a two-way protection given the potential of asymptomatic spread. This approach further drains the already overstretched supply of PPE. The more urgent situation has been accelerated by the increasing number of moribund patients and the lack of N95 respirators available for aerosol-generating medical procedures (AGMPs), such as intubation, bag-mask ventilation, non-invasive ventilation, or cardio-pulmonary compression. Each of these AGMPs have been shown to increase the risk of SARS transmission to HCPs. The most consistent association between AGMPs and HCP infection has been identified as tracheal intubation. [7] The situation seems dire, and global competition for PPE has resulted in demand far exceeding the available supply.

Sustainable options

One of the solutions to overcome PPE shortages is to avoid the need for AGMPs. In this context, regional anesthesia and sedation may represent a very attractive alternative and may become the “new normal.”[8] However, one must ensure that the sensory/motor block is appropriate for surgical anesthesia to prevent an urgent need for conversion to general anesthesia. Furthermore, level II PPE is still recommended even when avoiding AGMPs. This level of protection requires that HCPs don a surgical mask and barrier PPE while the patient also wears a surgical mask to prevent droplet transmission, with or without supplemental oxygen delivered beneath the mask.[9]

An alternate solution is to adopt reusable options, and this has prompted the U.S. Food and Drug Administration (FDA) to approve reusable industrial elastomeric respirators and a decontamination system for single-use N95 respirators amid the COVID-19 pandemic.[10],[11] It seems somewhat intriguing that not many reusable options for PPE were evaluated and approved by FDA prior to the COVID-19 pandemic. The notable advantage of reusable equipment, such as powered air-purifying respirator (PAPR), is sustainability. With the current pandemic of unknown duration, sustainability will ensure HCPs protection while reducing the environmental burden. Reusable PPE options also offer robust protection with high quality materials, whereas the disposable options are often of inferior quality and are worse for the environment. The only substantial advantage of disposable PPE is that cleaning/decontaminating is unnecessary. (Table 1) The significant increase in PPE utilization has generated a significant solid waste burden without a feasible path to recycling due to the uncertainties of virus transmission.


Table 1. Advantages and disadvantages of reusable and disposable personal protective equipment (PPE)

 

Advantages

Disadvantages

Reusable

  • Sustainable
  • Durable
  • Less environmental burden
  • Higher quality material

 

  • Needs proper cleaning protocol after use
  • Need safe storage after use
  • Needs training to doff and decontaminate

 

Disposable

  • Lightweight
  • No need for decontamination after use (less risk of self-contamination during cleaning)

 

 

  • Heavy environmental burden
  • Vulnerable supply chain management especially in a pandemic/epidemic
  • Less durable
  • Lower quality material
  • May self-contaminate when doffing

In Edmonton, Canada, the routine use of sterile, reusable, water-proof surgical gowns as normal attire in the operating room predates the pandemic. During the pandemic, these gowns are now laundered, without sterilization, for use as a component of HCPs PPE. Reusable goggles and face-shields are also used and can be cleaned and decontaminated very easily. Some anesthesiologists use a cotton towel, which again is part of the normal supply in the operating room, as a neck-cover during AGMPs. Elastomeric respirators are also available and many anesthesiologists in Edmonton have been fit-tested on these devices to ensure that PPE remains available should our normal supply of N95 respirators become uncertain. The main disadvantage of reusable respirators are the challenges associated with removing this equipment (doffing) without self-contamination and the lack of validated mechanisms to ensure that devices are reliably cleaned following use. Therefore, the sudden need to generate evidence for safe performance of equipment in a timely manner is often challenging. This begs a question of awhether there should be further investigation in sustainable equipment prior to an actual pandemic because without PPE, HCPs cannot operate safely in a “hot zone.” [12]

Conclusion

In the last decade, there has been a shift toward disposable equipment and attire in the operating room that has been generated predominantly by external marketing forces. The environmental burden has further increased during this pandemic. Perhaps a lesson learned from this pandemic is that there is a need to take a closer look at the sustainability of our collective PPE. There is an incredible similarity between PPE supply amid the COVID-19 pandemic and climate change, where sustainability ensures the safety of humanity and should not be overlooked. There should not be a need for a pandemic to examine our shortfall in protecting the health and safety of both the HCP and our planet.

References

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  10. Hinton D. US Food and Drug Administration approval of elastomeric respirator. https://www.fda.gov/media/135763/download (Accessed April 25, 2020)
  11. US food and Drug Administration approval of decontamination system for single-use N95 respirator. http://www.fda.gov/media/136529/download (Accessed April 25, 2020)
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