Doctors, nurses, laboratory staff and other healthcare professionals providing direct patient care have been reported to be at very high risk in combating the current Covid-19, and many have been tested positive by now and several others died very unfortunately as appropriate and adequate preventive measures were not in place, according to newspaper and electronic media reports. By the very nature of their occupation, healthcare professionals are exposed to many biological hazards, including hepatitis B, herpes viruses, rubella, tuberculosis and human immunodeficiency virus. The health and safety of healthcare professionals is generally ignored by the employers in Bangladesh just like that of workers in many other high hazard industries (e.g., construction, ship breaking, garment, brick-field and transportation). These other occupations are mostly at risk of physical and chemical hazards, while healthcare professionals are at risk of biological hazards which are equally or more deadly. The Covid-19 pandemic has blatantly exposed the vulnerability of our healthcare professionals. All policy discussions about protecting them have so far focused on the quality, quantity and access of personal protective equipment (PPE); however, providing PPE is only one part of an overall health and safety (H&S) programme in a hospital.
PPE must be considered as a component of various other prevention measures against occupational hazards that exist in hospitals. Good knowledge of the kinds of PPE used in hospitals, the hazards for which these provide protection against and the standards for selecting appropriate PPE is only one step toward ensuring safety. The manufacturers and suppliers of PPE and the hospital administration must educate the users where and when they are relevant. PPE is only a part of the overall health and safety (H&S) programme to decrease the distinctive risks found in a hospital. In the hierarchy of protective measures to control hospital hazards, PPE is not the only one to bring changes. In reality, it will be effective when other engineering controls which reduce the hazard (such as separation, enclosure, ventilation or substitution) and administrative policy controls (such as reducing or alternating the work shift at wards or units where COVID-19 positive patients are cared for) are also employed.
PPE must be used as part of a comprehensive H&S programme in a hospital which should include: (1)evaluation of the hazards; (2) selection and fitting of PPE; (3) training and education for healthcare professionals; (4) maintenance and repair to keep PPE in full working conditions; (5) active involvement of hospital management; and (6) motivation of healthcare professional to comply.
There are PPEs that are quite easy to use, such as gloves and goggles; however, there are other PPEs such as respirators that are quite complex to use. PPE's effectiveness depends upon change in human behaviour and changing behaviour is always a very difficult undertaking. The vital components of a functioning H&S programme in a hospital are described here briefly.
Understanding the category and nature of the exposures and its connection to the overall work environment in a hospital is very important. Leaving loopholes in this evaluation step may lead to selecting inappropriate PPEs which may make the hospital employees reluctant to use or they may refuse to wear the equipment. It is necessary to know the composition and concentration of the biological, chemical or physical agents, the expected shelf-life of PPEs during which it will provide full protection, and the nature of patient care activities performed while using the equipment. This assessment of the hazards must be completed before choosing the PPE.
PPE can be selected to adequately protect healthcare professionals by knowing about the nature and extent of the hazard, the level of defence provided by them, and the quantity or concentration of the hazard that is around while PPE is in use. Manufacturers of respirators have the data on the performance of their equipment and they must provide it to the hospitals. There are guidelines and standards of selecting PPEs, particularly for respiratory protection by several international agencies.
PPE must be properly fitted if it is to deliver the degree of intended protection. Proper fit is also an important factor in the acceptance of the PPE and the motivation of healthcare professionals to actually use it. Ill-fitting or uncomfortable PPE should not be used. Poorly fitted PPE may even create more hazard for health professionals by giving a false sense of protection and creating dangers for them, their colleagues and patients. Manufacturers of PPE offer a series of sizes and models of PPE, and hospital professionals should be provided PPEs that fit properly to serve their purpose. In the case of respiratory protection, specific requirements for fitting are set by several international agencies including Occupational Safety and Health Administration in the United States. This importance of assuring proper fit applies to all kinds of PPEs. Effectiveness of a H&S programme in a hospital requires full participation and commitment by its employees who are to benefit from it and from the management which offers and implements this programme. H&S programmes will not succeed if the healthcare professionals are not educated and trained on the importance and the availability and utility of all prevention measures. Those responsible for the H&S programmes in a hospital must have the knowledge and skills to select proper PPEs. They must also learn from the suppliers of PPE how to repair, maintain and clean the PPE as well as the training to identify any wear and tear during its use. The consequences of unprotected exposure need to be plainly and openly explained, as well as the means by which users can identify when the PPE is not working appropriately.
Just like any other mechanical equipment and device, PPEs also degrade in performance over time. It is very important to recognise that there are costs of maintenance, repair, and replacement in operating a H&S programme in a hospital. Some PPEs need to be disposed after single use while others are reusable. In the case of reusable devices, the maximum length of work shift allowed is very critical to know before it is substituted. Some PPEs need to be used only once and must be discarded whereas protective suits which have been contaminated by previous use must go through a prescribed cleaning process before it can be reused. The decision rules must be made and ensured by the hospital authority when to discard a PPE even when it is expensive, when it is degraded in performance, or when it is contaminated.
PPEs are essential parts of a hazard control strategy in a hospital. However, the use of PPE must be supported by a well-designed and functioning H&S programme.
Dr. Hasnat M. Alamgir is a Professor of Pharmacy at East West University, Dhaka, Bangladesh. He has a PhD in Epidemiology from Canada. email@example.com