For most of us, we have never experienced a pandemic as unique and widespread as COVID-19 during our lifetimes. There is ample data suggesting that the novel coronavirus is not only more infectious (R-naught 2-3) but also associated with increased severity of disease (average case fatality rate of 2.3 percent) than the seasonal flu. We are slowly understanding how intelligent and damaging this virus can truly be given the varying length of its incubation period of 2-14 days, viral shedding before symptom onset, and its ability to survive on surfaces. Because the virus is spread via droplets, and can be aerosolized, frontline health care workers (HCW) need to wear personal protective equipment (PPE) such as N95 respirators, surgical masks, gowns, gloves, and eye protection to keep themselves safe from getting infected. If the United States continues to have wide community spread and exponential increases in the number of cases of COVID-19, this surge of patients will not only place increased demand on hospitals beds/critical care resources but will require urgent federal and state support to ensure adequate PPE for all frontline HCW to keep them safe.
While all health care facilities have been preparing for weeks-months stockpiling supplies for the possible surge of patients infected with COVID-19, most health care administrators have been struggling to order basic supplies due to global production and distribution delays and are concerned about the realities of dwindling inventories. In Washington state, an institution that was following World Health Organization PPE guidelines, after 2-3 weeks of their local outbreak, there were severe shortages of PPE, with rationing of N95 masks, reusing of disposable face shields after cleaning, and staff burnout around PPE. Other hospitals across the US are facing similar shortages, and we are concerned that with the rising cases, and quickly dwindling supplies of PPE, health care facilities will need to adopt varying guidelines to accommodate PPE rationing, or possibly reusing and repurposing in ways manufacturers never intended, potentially putting front line HCW at risk of getting infected. As health care facilities are rapidly evolving to ensure they provide exceptional care for the most number of patients, it must be the priority of local and federal government to ensure frontline workers are properly equipped, kept safe, and can continue doing their job. Multiple professional medical and public health groups including emergency medicine, infectious disease physicians and nursing unions have already appealed to their community leaders and congress for emergent action, conservation, and access to PPE but despite emergency budget increases, the exceedingly concerning federal response to date is for state governments is to “try to get it yourself.”
Why is the protection of health care workers’ health important? We know that during the SARS outbreak in 2002, 1/5 of all cases were in HCWs. If a HCW is exposed to a person under investigation for COVID-19 without adequate PPE, they must be quarantined to monitor for symptoms or in the worst case, will get sick themselves. This would prevent them from being able to provide clinical care to the exponentially rising number of critically ill patients. If many HCWs are unable to work either due to quarantine or illness, who will take care of you or your family members if they were to get sick?
Based on the summary report from the Chinese Center for Disease Control and Prevention, 3.8 percent of all infections were health care personnel (1,716 of 44,672 patients), of which 14.8 percent had severe/critical illnesses, and five died. Looking at integrated surveillance data out of Italy, earlier in their outbreak 1,116 health care workers infected with COVID-19 out of 13,882 cases. Because of this, in order to protect and preserve hospital staff, some Italian hospitals recommended a higher level of protection than current WHO recommendations, including FFP2 masks, N95 masks, and above, waterproof gowns, and full cover. The HCWs getting infected with COVID-19 are not only seen internationally, but domestically we are seeing increasing numbers of HCW exposed, infected, and some of our colleagues are unfortunately in critical condition. Thus, an adequate supply of PPE is essential, and both state and federal support are needed.
In most of our lifetimes, we have never witnessed a war against a virulent viral infection that has affected so many across the globe. Similar to military battle, we could never fathom sending our soldiers to war grounds without proper protection, armor, and weaponry. Our HCW will be on ground zero in their hospitals, and adequate PPE will be crucial and necessary in keeping them safe. We appeal to our political leadership to ENSURE that there are adequate PPE stocks available in every single health care facility, NOW, so that 1-2 weeks from now, when we are seeing a higher volume of patients, we are keeping frontline HCW safe.
We recognize that there have been global shortages and our hospital administrators have been doing everything to help us stay safe, but given the magnitude of our pandemic, it is time for the federal government to step up and help each state develop a sustainable mechanism so they can have a steady supply of PPE to keep their HCWs safe. An example of best practices being done in Thailand includes ramped up domestic manufacturing of N95 masks. Other possible ideas could include providing access to federally regulated Strategic National Stockpiles or seeking alternative non-medical suppliers for assistance.
As HCWs, we have taken an oath to care for all patients and are ready to fulfill our responsibility by spending long hours to save our community from this COVID-19 pandemic. As we have seen in other countries and domestically, we know that many of our colleagues or I could get sick caring for patients, despite adequate PPE. But, if HCWs run out of PPE, the basic tools that we use to protect ourselves, society will have to face the horrible consequences of mass quarantined staff who are unable to provide medical care, and put our most valuable and selfless medical community at highest risk of infection, or death. We call for United States federal and state government support to expedite mechanisms to ensure every frontline HCW and health facility has adequate PPE now.
Raagini Jawa is an infectious disease fellow. Amal Jawa is a hospital administrator.
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