We live in strange times, considering the current Covid-19 pandemic, caused by the transmission and infection of the SARS-CoV-2 virus.
In fact, the last similar pandemic of such magnitude was the 1918 influenza outbreak a century ago!
SARS-CoV-2 is known for its “stealth-like” infection as it can survive in humans without causing any symptoms from two days up to two weeks, and in some people, throughout their entire infection.
Its magnitude, resilience and rapid transmission has caught many by surprise, leaving nations, healthcare workers (HCWs) and the public scrambling for adequate personal protective equipment (PPE) overnight.
PPE includes any equipment that protects an individual from health or safety risks. In an industrial setting, it includes head gear, eye protection, visible coating and safety footwear.
In a healthcare setting, it includes head covers, fluid-resistant surgical or N95 masks, disposable gloves, long-sleeved fluid-repellent gowns or aprons, eye goggles, face shields, and boots or closed shoes.
The need for PPE
Each SARS-CoV-2 virus is spherical in shape, with a diameter of approximately 125 nanometres, and is invisible to our naked eye.
It is believed to spread via close contact with infected aerosol droplets, where the virus may enter our body via breathing in these droplets or by touching a contaminated surface, then touching our exposed organs, which are not covered by the protective barrier of skin, such as the eyes, nose and mouth.
It may also be spread by infected people who do not show any obvious symptoms of Covid-19.
A recent study published in the New England Journal of Medicine, which looked into the stability of SARS-CoV-2 in a lab, discovered that the virus would linger for less than four hours on copper, 48 hours on stainless steel and 72 hours on plastic.
This explained a case in Singapore, where a 52-year-old woman occupied a seat in a church that was earlier occupied by two asymptomatic (i.e. showing no symptoms) Covid-19-positive tourists.
She subsequently developed Covid-19, even though closed circuit cameras did not reveal any other symptomatic attendees that day.
Avoidance is the best prevention for Covid-19, which is why the movement control order (MCO) was implemented by the Government beginning March 18 (2020).
However, many of us still require visits to the supermarket, while others in essential industries such as healthcare, public security, transportation, food, water, energy, solid waste and communications, still need to work, thus risking exposure.
From a healthcare perspective, the long duration of no symptoms (asymptomatic), despite being infected, means that every potential patient or HCW may be an asymptomatic carrier of the virus.
In light of emerging data that there is a significant proportion of Covid-19 patients who are asymptomatic (up to one in four patients), the need for adequate PPE for all is undeniable.
For the public
Given that SARS-CoV-2 was discovered less than five months ago, there is still plenty of new research and information pouring in daily.
Currently, the jury is still out on whether the general public should wear a face mask when going out to shop for essential items.
However, if there is a lesson to be learned from history, something is always better than nothing.
We have probably seen old pictures and public notices from the 1918 influenza outbreak on social media, reminding the masses to avoid group gatherings and to wear a mask.
The World Health Organization (WHO) has published guidelines on basic protection against the virus, which include practising hand hygiene by washing your hands with soap and water regularly, social distancing, and respiratory hygiene by covering your mouth and nose when coughing or sneezing.
It advises wearing face masks (as of Jan 29) if an individual is looking after a person with a suspected Covid-19 infection and if one is coughing or sneezing.
The organisation notes that wearing a face mask is only effective if it is accompanied by good hand hygiene.
Face masks must also be worn, taken off and discarded in the proper manner.
For healthcare workers
PPE for HCWs is more complex than those for the general public, and is dependent on the level of exposure to a Covid-19 patient.
In China, nearly 3,400 HCWs were infected with Covid-19, with at least 13 dying from the disease.
In a study in Wuhan, it was believed that 29% of patients infected in a single healthcare centre were HCWs.
Their likelihood of an infection was three times higher than the general population.
According to China’s Centre for Disease Control and Prevention director Dr George Gao, face masks play a very important role in preventing disease transmission as many patients have no symptoms.
As of April 11 (2020), 224 HCWs in Malaysia have been infected with Covid-19, with one doctor dead from the disease.
Some of these cases are due to patients not revealing their close contact with Covid-19 patients or persons under investigation (PUI), or their attendance at cluster events.
In fact, a private hospital in Sungai Petani, Kedah, had to shut down temporarily last month (March 2020) after a pregnant patient admitted for delivery, failed to disclose that she was a close contact of a Covid-19 patient.
This has led to questions about the reliability of patients when giving their history and answering Covid-19-related questions, which increases the danger to HCWs of exposure to the virus.
PPE becomes even more important in this scenario.
The Health Ministry has clear guidelines on the minimum PPE required for HCWs.
These can differ depending on whether the HCW is in contact with a confirmed Covid-19 patient, the types of procedures to be carried out and many more.
At the least, all HCWs with patient contact should don a face mask.
For those performing activities like physical examination, blood-taking, nose or throat swabs, transporting patients, and even cleaning or decontaminating a room, a full set of PPE should be donned.
Assuming that everyone is Covid-19 positive until proven otherwise, means that HCWs should be allowed to wear PPEs in most scenarios.
The guidelines are also applicable to janitors working in healthcare institutions, who need to don surgical masks, long-sleeved aprons/gown, gloves, eye protection and closed shoes while working, as they too may be exposed to the virus when dealing with soiled linen and surfaces touched by Covid-19 patients.
The protection required increases to powered air-purifying respirators (PAPRs) and Tyvec suits for any airway procedure involving aerosol droplets among PUI or Covid-19 cases.
The dilemma is that many of these items are of one-time use and will have to be discarded once used or exposed to a patient.
Only a PAPR can be reused, but it requires a thorough medical grade disinfection.
Hospital Canselor Tuanku Muhriz (HCTM) director Professor Datuk Dr Hanafiah Harunarashid notes that the process of putting on and removing PPE is complex and requires practice.
A wrong step may easily cause contamination to the HCW.
Other items that can help protect HCWs include isolation pods and protective head boxes.
For example, HCTM has 12 isolation pods that can be used to transport Covid-19 patients safely and minimise the risk of transmission to HCWs.
Several transparent protective head boxes, which are placed over a patient’s head to help reduce the HCWs’ exposure to a Covid-19 patient’s infected droplets during direct intubation, were also dona-ted to the hospital.
Currently, the world is facing a shortage of PPE due to the magnitude of this pandemic.
Measures to reuse PPEs or conserve PPE by reducing elective operations have only helped a little.
However, in the past weeks, we have seen many HCWs being innovative in utilising plastic garbage bags to make head covers and arm and leg wraps, to form full body suits as an alternative to proper PPE.
No doubt they are uncomfortable and warm – so warm that wearing them for prolonged duration may result in dehydration!
Another innovation is self-made face shields that are cheap and easily reproducible from items such as raffia strings, sponges and clear plastic sheathes, which are all available from bookstores.
The local 3D printing and design communities are also helping to produce face shields for HCWs.
The abundance of PPE donations recently comes as a much welcomed move by HCWs.
It is impossible to maintain a functional medical service without the HCWs, and they, in turn, cannot function without adequate PPE during this pandemic.
It is hoped that all our HCWs will have sufficient PPE to carry out their duties safely and confidently during these precarious times.
Dr Hardip Singh Gendeh and Dr Danny Wong are ear, nose and throat (ENT) surgeons at HCTM in Kuala Lumpur and KPJ Healthcare University College in Negri Sembilan respectively. For more information, email firstname.lastname@example.org. The information provided is for educational purposes only and should not be considered as medical advice. The Star does not give any warranty on accuracy, completeness, functionality, usefulness or other assurances as to the content appearing in this column. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.
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