The primary role of personal protective equipment (PPE) within the healthcare environment is to either protect the patient from the health are worker or the healthcare worker from the patient. Both patients and carers can be vectors of infectious disease.
Background
In 2016, the NHS as a whole failed a major cross-government test of its ability to handle a severe pandemic. The results of this Emergency Preparedness, Resilience and Response (EPRR) exercise, known as Exercise Cygnus, however, were not revealed to the public. The 3-day exercise looked at the impact of a pandemic influenza outbreak with a similar magnitude and death rate to the current pandemic, and the significant impact such a pandemic would have on health delivery. After the exercise, ministers were informed that it was likely the country would be quickly overwhelmed during a severe outbreak amid a shortage of critical care beds, insufficient morgue capacity and lack of PPE.
The Health and Safety Executive (HSE) has made it clear that PPE is important in making the workplace safe and this includes providing instructions, procedures, training and supervision to encourage people to work safely and responsibly (HSE, 2018). Similarly, the Care Quality Commission (CQC), the healthcare regulator for England, has developed an inspection framework setting out five domains that inspectors use to assess whether providers such as NHS trusts are safe, effective, caring, responsive to people's needs, and well led (CQC, 2018).
Perhaps of all these domains ‘safe’ is the most important and by safe the CQC means that staff, service users and their families are protected from abuse and avoidable harm. Avoidable harm includes being protected against acquired hospital infection and the CQC specialist advisers go to great lengths to assure themselves that the individual clinical areas being inspected abide by national standards for the prevention of infection. Hence, how standards of cleanliness and hygiene are maintained is assessed and inspectors seek evidence that there are reliable systems in place to prevent and protect people from a healthcare-associated infection.
Crucially, this includes the provision of PPE. The CQC also checks that staff members receive effective training in safety systems, processes and practices, so that PPE can be used effectively. Trusts are required to ensure that these aspects of mandatory and statutory training are embedded in the training and development strategy. It is usually practice educators who monitor staff compliance with these requirements and the CQC inspectors will assess a sample of staff electronic personal records to verify and triangulate the data they have been given by a trust on mandatory training compliance statistics.
Historical aspects of infection protection
Epidemics, plagues and pandemics have occurred throughout history in parallel with the development of civilisation. It can be argued that infectious disease in humans was caused by their own urbanisation. Once we adopted a more agrarian lifestyle about 10 000 years we grew crops and domesticated animals, leading to the development of larger settlements, with animals living cheek by jowl with humans, thus precipitating the spread of zoonotic diseases, such as COVID-19.
The novel coronavirus is related to other coronaviruses, such as SARS-CoV [severe acute respiratory syndrome coronavirus], hence its designation SARS-CoV-2 by the World Health Organization. Coronaviruses are thought to spread indirectly from wild animals, such as bats, via intermediary animals such those sold in the so-called wet market of Wuhan City in China, which was shut down in January after the outbreak of COVID-19, the disease caused by the virus, although it has since reopened (Think Global Health, 2020).
In the distant past, early humans used magical formulas, religious incantations, charms or magical objects to prevent illnesses and infection. Later, they adopted potentially more practical solutions to preventing the spread of disease. For example, during the great plagues physicians tending the afflicted would wear masks with a bird-like beak filled with scented herbs and spices that they believed would protect them from the infection. They thought that the infection was airborne and spread via miasma, a noxious form of ‘bad’ air, and that the masks would offer protection.
Ironically, although the miasma theory of infection has long been ridiculed by scientists there is emerging evidence suggesting that the Black Death may have been a pneumonic plague spread through coughs and sneezes similar to influenza and coronavirus. However, there has been no definite evidence as to exactly how long coronavirus remains in the air and remains infectious in different spaces and the optimal distance people should keep between them to reduce the risk of infection.
Social distancing and household lockdown have become a stalwart aspect of the current pandemic as a way of controlling the R factor, or the number of people to whom an infected individual will pass the virus. Estimating the R for SARS-CoV-2 or its capacity to spread has become crucial in managing the spread of COVID-19.
The lockdown as a means of preventing the spread of disease is not new. Perhaps the most famous example of self-isolation occurred during the great bubonic plague of the 17th century when the population of a Derbyshire village affected by the plague decided to shut themselves away from the outside world to protect their neighbours. (Beaumont, 2020).
The practice of quarantine has its origins in the 14th century when ships arriving in Venice from known infected ports had to remain at anchor and self-isolate for 40 days (quaranta giorni means 40 days in Italian). Subsequently, the raising of a yellow quarantine flag was introduced to indicate infection aboard a ship.
Conceivably, it was the work of Hungarian obstetrician Ignaz Philipp Semmelweis in the 19th century that led to the first reliable method of personal protection for both healthcare staff and patients. Semmelweis advocated washing hands in a chlorinated lime solution as a way of reducing the incidence of puerperal sepsis, which claimed many lives among recently delivered mothers. The infection was caused by doctors not washing their hands after conducting autopsies on women who had died of puerperal sepsis. After the introduction of handwashing the rate of infection among this group of postpartum women fell dramatically (Smith et al, 2012).
Today, handwashing remains the primary means of stopping the spread of many types of infection and is a major facet in the Chief Medical Officer's advice to the public in the current crisis.
Protecting health care workers on the frontline of service delivery
In a letter to the CQC written on 1 April 2020, the Chief Commercial Officer for the Department of Health and Social Care (DHSC) acknowledged that there had been challenges for healthcare providers in obtaining sufficient PPE supplies during the pandemic (DHSC, 2020a). The letter came as news emerged of healthcare staff resorting to fashioning their own PPE from clinical waste bags, plastic aprons and borrowed skiing goggles.
The full complement of PPE in the context of a virulent pandemic such as COVID-19 consists of a range of equipment that includes medical masks, visors and face shields/goggles (this stops the virus entering through the eyes but can cause skin problems for the wearer after a long shift), gloves, gowns and shoe coverings. The complexity of full PPE for delivering direct care to COVID-19 patients is necessary to protect the staff wearer against acquiring the infection through direct touch of contaminated objects or via droplet and airborne transmission of the virus.
Given the controversy surrounding the issue of PPE supply to frontline health workers the government has issued with specific instructions on the use of PPE during the pandemic. Importantly, a staff member can wear the same PPE for the duration of a clinical shift and when leaving a ward to continue caring for or transferring a patient. The government has stated that face masks/respirators, gowns/coveralls and eye protection should be changed only when staff members are taking a break or when the equipment is visibly contaminated or damaged (DHSC, 2020b).
Similarly, undamaged PPE equipment can, with appropriate precautions, be reused by the same health worker, subject to a range of caveats, including that (DHSC, 2020b):
It is important to stress that the government has publicly stated that the safety and wellbeing of NHS staff and students is its number one priority (DHSC, 2020c). However, despite this affirmation, Medscape, the online information resource for physicians and health professionals, conducted a UK poll among its readership showing that staff are still experiencing difficulty in getting the right PPE at the right time. Furthermore Medscape has highlighted that most PPE in the NHS is designed for the male body, and not the female body (Locke, 2020).
It is feared that next wave of COVID-19 will begin to infect the population in the autumn of 2020, so it is to be hoped that the NHS will be better prepared with the right amounts of PPE for all its workforce.