An Assessment of Awareness, Preparedness and Availability of Personal Protective Equipment among Frontline Healthcare Providers in India during the COVID-19 Pandemic

Introduction

On March 11, 2020, the World Health Organization declared COVID-19, a respiratory infection due to SARS-CoV-2, as a global pandemic. Novel Coronavirus (COVID-19) is an infectious disease caused by a newly discovered virus that belongs to the Ortho Coronaviridae family.¹ Globally 4,101,889 coronavirus cases were reported by 10th May 2020 out of which 2,80,443 people had died worldwide and 1,441,815 recovered from coronavirus (WHO, 2020).² In India, around 63,000 were infected by the coronavirus and 2,109 had died of COVID-19 (10th May, 2020) as declared by Union Ministry of Health and Family Welfare (MoHFW).³ The outbreak of novel coronavirus disease (now named COVID-19) was initially reported from a seafood market in Wuhan city in Hubei province of China in mid-December, 2019 and currently had spread to more than 185 countries worldwide.COVID-19 virus is primarily transmitted among people through respiratory droplets and oro-nasal contact routes. Droplet transmission occurs when a person is in close contact (within 1 m) of another who has respiratory symptoms such as cough or sneezing and therefore at a higher risk of having his /her mucosa (mouth and nose) or conjunctiva (eyes) exposed to potentially infective respiratory droplets. Transmission of the COVID-19 virus can occur by direct contact with an infected person and indirect contact with surfaces in the environment or with the objects used by the infected person. The incubation period varies from 2 days to 15 days and the fatality rate of this virus has varied across countries with the highest fatality rate seen among older adults with co-morbidities or chronic health conditions such as cardiovascular disease, diabetes, chronic respiratory disease, and cancer and these individuals are more prone to develop serious illness. In Italy, the case fatality rate was found to be five times higher than in India. As there was no confirmed cure available for the illness initially, many countries had begun to use antimalarial medicine such as hydroxychloroquine, the antiretroviral drug Remdesivir and plasma therapy in COVID-19 patients with varying success. The world has been working on vaccine development and many of these are expected to be available to the general public in the second half of 2020.⁴ Healthcare-associated infection of SARS-CoV-2 virus has been commonly seen among healthcare workers across countries. In India, an initial media report had mentioned that 50 health professionals became infected with the corona virus (Print, 2020)⁵ as these healthcare professionals were having direct contact with COVID-19 patients. As the pandemic accelerates, access to personal protective equipment (PPE) for health workers is a key concern. Medical staff is prioritized in many countries, but PPE shortages have been described in the most affected facilities. Some medical staff is waiting for equipment while already seeing patients who may be infected or are supplied with equipment that might not meet standard requirements. Alongside concerns for their personal safety, health-care workers are anxious about passing on the infection to their families. Healthcare workers who return home to care for elderly parents and/or young children have been drastically affected by school closures, social distancing policies, and disruption in the availability of food and other essentials (Lancet, 2020). Personal Protective Equipment (PPE) is protective gear to safeguard the health workers by minimizing the risk associated with the infection. PPE kits can consist of goggles, face-shields, masks, gloves, coverall /gowns (with or without aprons), head cover and shoe cover (MoHFW, 2020).⁶

The Ministry of Health and Family Welfare Directorate General of Health Services (MoHFW, 2020) had laid down standard guidelines for the use of Personal Protective Equipment (PPE) at points of entry to safeguard health workers against COVID-19. Health professionals had been instructed to use triple-layered medical masks at low-risk points such as health desks which provide information to travelers, at immigration counters, customs, and airport security, temperature recording stations, etc. In moderate-risk areas, health workers were recommended to use the N95 masks and wear gloves. In the holding area/ isolation facility of APHO/ PHO, sanitary staff has been advised to use an N95 mask and gloves. A full complement of PPE will have to be used by health workers who are attending severely ill patients where aerosol-generating procedures are anticipated.⁷ In hospital settings where there is moderate risk, N95 masks and gloves are recommended to be used in the triage area, screening area, help desk/ registration counter, temperature recording stations, holding area/ waiting area, doctors chamber, sanitary staff and accompanying young children and elderly.

In case of in-patient services where there is moderate risk such as in individual isolation rooms/ cohort isolation rooms, sanitation area, etc. the health workers were recommended to use N95, gloves and in ICU/ critical care where high-risk, they are recommended to follow the full implementation of PPE. In low-risk areas, triple masks and gloves can be used in non-COVID-19 treatment areas of the hospital and by caretakers accompanying the admitted patient. In the Emergency Department while attending emergency cases where risk was assessed as moderate health professionals were recommended to use N95 mask, gloves. However, while attending to severely ill patients of SARI health workers were recommended to use the high-risk full complement of PPE.⁸

In case of other supportive/ ancillary services such as the laboratory where sample collection and transportation or where sample testing is done it is recommended to use the high-risk full complement of PPE. For the mortuary where bodies may be handled, it is classified as moderate risk and health workers should wear the N95 mask, gloves should be used while performing an autopsy and in case of high risk they must use the full complement of PPE. In case of sanitation and CSSD/ laundry services which are under moderate risk, health workers should be using the N95 mask and appropriate gloves. With regards to quarantine facilities where persons are being quarantined, the designated family member should wear triple-layered masks and gloves. For all health workers in community settings such as the ASHAs/ Anganwadi workers and other field staff and including doctors at the supervisory level who are conducting field investigation, the use of triple-layered masks and gloves is recommended. The recommended guidelines issued by MoHFW also advise washing your hands or using an alcohol-based rub frequently and not touching your face and the mandatory use of a mask in public places

Background

COVID-19 has been declared a pandemic by the World Health Organization (WHO). By May 2020, it had spread to 185 countries in the world and the numbers of cases were increasing in India. The pandemic has exerted a lot of strain on the health care providers and the primary health setup in scarce resource settings. The increased expenditure required to train workers, procure and provide PPT rationally to frontline workers has been a concern. It is known that the appropriate use of PPE will help healthcare providers to deal with the risk of treating patients suspected of COVID-19 infection and also help with prudent use of PPE and managing shortages. It was recognized by mid-2020 that unless the supply of PPE was quickly replenished or viable alternatives to traditional equipment were devised in the coming days to weeks, hospitals and healthcare systems will face the difficult task of rationing PPE to at-risk healthcare professionals. Most of the developed countries such as the UK, Italy, US, Russia are facing a shortage of PPE in their countries too. Developed countries which had the best health care facilities in the world saw their healthcare systems collapsing due to the coronavirus pandemic and faced difficulties with frontline healthcare workers infected and some even fatally. It was recognized that although India seemed better off in terms of the case fatality rate shortage of PPE was bound to occur and had to be overcome. To overcome this shortage, the government had recommended the public to use cloth masks which can be easily made in the home to prevent the acute shortage of N95and the triple-layered mask which were essentially required by the health workers for treating COVID-19patients.

The Ministry of Textiles and Ministry of Health and Family Welfare had together said that at present 3.34 lakh PPE were available in various hospitals across the country. About 60,000 PPE kits had already been supplied by the Government of India. China has donated 1.70 lakh PPEs to India too. However, by mid-2020-, there was a perceptible shortage of PPE in India. The shortage of medical equipment was also expected to be going to be the biggest challenge, although the government had already banned the export of these devices with immediate effect. China’s National Health Commission shows that more than 3300 health-care workers had been infected as of early March 2020 and, according to local media; by the end of February 2020 at least 22 had died. In Italy, 20% of responding health-care workers were infected, and some had died by March 2020.8 Around 50 doctors and medical staff had tested positive in India by then. It was also found that due to a shortage of personal protective equipment (PPE) at the hospitals, the doctors and medical staff had become vulnerable to COVID-19 while treating patients. Health-care workers are every country’s most valuable health resource and if hospitals are reporting shortages of key equipment needed to care for critically ill patients, including ventilators and personal protective equipment (PPE) for medical staff, then it is concerning. Adequate production and distribution of both types of equipment are crucial for patients during the pandemic. In India, there was a reported shortage of PPE kits and that the Government was planning to procure more PPE domestically and was also exploring imports from South Korea and China. The lack of adequate PPE for frontline health care workers, including respirators, gloves, face shields, gowns, and hand sanitizer was a challenge that had to be quickly overcome. We had already seen the narrative from Italy, where healthcare workers experienced high rates of infection and death partly because of inadequate access to PPE.

This cross-sectional study hence explores the current awareness and preparedness regarding PPE and protocols for their appropriate usage among frontline healthcare workers in India. Further, it also explores the need and status of availability of PPE among frontline healthcare workers in India. This study was conducted to evaluate awareness and preparedness regarding PPE and protocols for the same among frontline healthcare workers treating COVID-19 patients in India and to explore the need and status of availability of PPE in India among frontline health workers treating COVID-19 patients in India.

Materials and Methods

The study utilized two sets of data. The primary data regarding PPE need, availability, and awareness regarding PPE protocol to be followed while treating COVID-19 patients was collected from a purposive sample of frontline healthcare workers including doctors, nurses and paramedical staff. The questionnaire developed for the same was shared among medical professionals through Google forms and only those professionals working in frontline care duties and treating COVID-19 patients answered the questionnaire. Informed consent was obtained from all the respondents and respondents could withdraw from the study anytime during the survey. Confidentiality was assured to all respondents. The survey was prepared in the form of an online form and was sent to 87 healthcare providers. Out of 87, only 65 of them answered the questionnaire indicative of a response rate of 74.71%. The self-administered questionnaire consisting of awareness regarding PPE and availability and 23 questions were based on knowledge and PPE practices related to COVID-19 disease in healthcare settings. The period of the survey was April 17-22, 2020, and a total of 65 respondents completed the survey. All of the participants demonstrated a clear understanding of the questionnaire. Convenient sampling method was used for data collection, and the distribution of responses was presented in the form of descriptive statistics. Appropriate categories were recorded on the basis of gender (Male, Female), Age Groups (21-25 years, 26 to 30 years, above 30 years) and current professional attainment (undergraduates, graduate students, faculty from medical, dental, nursing institutes, and administrators. The data were entered and descriptive statistics were performed using MS Excel. The secondary data came from an extensive literature review conducted through online searches, namely Pub Med up to 15th April 2020), MoHFW, WHO, Google scholar (EBSCO host up to 15th April 2020), and OSHUpdate (upto 15th December 2020). These sources have been utilized in identifying the objectives, preparing the study tools, the background and summarizing the discussion of this article.

Results

A total of 65 healthcare professionals responded to the survey. A majority of the respondents were from the age group of 26-30 years with an average age of 26 years. The subjects consisted of healthcare professionals who were working in government and private hospitals in India and were actively treating COVID-19 patients. The proportions of respondents in terms of gender were nearly equal. Around 41.54% of the respondents were pursuing post-graduation in a medical college while 21.54% of them had completed their post-graduation. The sample also consisted of nearly 28% of respondents who had completed their graduation while the rest were still interning at their medical college. The proportion of the respondents who were working in various clinical departments – 15% in medicine, 15% in surgery, 14% in healthcare operations role, 11% in emergency medicine, 9% in clinical pharmacy, 8% were dentists while a major proportion of them were handling clinical roles in departments such as Cardiology, Anesthesia, Psychiatry, ENT, Ophthalmology, and Gynecology

Table 1 provides details regarding the socio-demographic characteristics of the frontline healthcare workers who answered this survey:

Table 2 below provides a summary of the awareness that these healthcare providers had about the use of PPE while treating COVID-19 patients.

Most of the respondents were aware of the components of PPE but most of them had not used PPE. Approximately 49.23%of the respondents had not used PPE ever during their clinical duties and as high as 60%ofthe respondents were not provided PPE on a daily basis. However, most of the respondents were aware that PPE can help them protect them from COVID-19 infection. Respondents were using different types of masks in their hospital duties. Figure 1 below provides the responses of the healthcare workers to the effectiveness of PPE in protecting them from COVID-19 infection.

With respect to the use of face masks by healthcare workers, we realize that 50.77% of respondents used the N95 Respirator mask during clinical duties following by 44.62% using triple-layered medical mask and 4.62% of them using cloth masks.

Interestingly only 47.69% of the respondents were sure about having been demonstrated the appropriate method to wear the PPE and the precautions to be followed. 29% of them confirmed that they had been trained by professional peers and another 29% of them had followed WHO/MoHFW/ICMR guidelines regarding the use of PPE. Around 46% of the respondents confirmed that they had received training on how to wear PPE, duration of usage, and regarding the appropriate method to dispose or sterilize the PPE.As high as 95% of the respondents were interested to receive guidelines and/or trainings to help understand the correct method to use and dispose the PPE. As high as 80% of the respondents wished that the government could provide the PPE free of cost to frontline healthcare workers across hospitals.

Only 24.62% of the respondents confirmed positively that they had been provided with appropriate PPE kits during their clinical duties. Another 23.08% of them said they probably received the PPE while 20% of them were unsure.

Discussion

Although the study sample corresponded to different hospital centers in different cities in India, the sampling was non-random. The findings lead us to believe that in terms of awareness, availability and training received regarding the use of PPE by frontline health workers, much more can be done and there is a need to constantly monitor the implementation of PPE regimen in all types of hospitals. Healthcare professionals in India may face more difficulties than those from other countries with a high proportion of respondents reporting that they did not have the necessary resources to care for patients with COVID-19. It is very important that technical and logistical difficulties should be addressed in the event of a future outbreak, as they have a negative impact on healthcare workers. With as low as 25% of the respondents confirming that they received appropriate PPE during their clinical duties handling COVID-19 patients it a cause for worry and points to the fact that unless frontline healthcare workers are supported in their role, it is difficult to expect them to carry on with the same motivation to care for their patients. It is no doubt that the COVID-19 pandemic has exerted a strain on scare resources in healthcare and a worrisome fact is the shortage of PPE in hospital settings. While there are no convincing findings on the re-use of PPEs, several studies have pointed out that sterilization of used PPE with agents such as ethylene oxide, UV or gamma irradiation, ozone, and alcohol are appropriate and several others have reported of novel proposals such as mask-fiber impregnation with copper or sodium chloride.⁹ There is also some evidence that the fibers in masks and respirators that filter viral particles can degrade and lose their efficacy with PPE reprocessing.¹⁰ Cloth gowns and masks however can be easily produced and stored and laundry capacity could easily be expanded by recruiting commercial launderers that service hotels and other large organizations during this time. Sewing masks, creating the masks out of clothing, using novel materials to form them, and using cloth sleeves to increase the utilization of N95 respirators are novel methods to overcome shortage as well as enthuse the small-scale manufacturers.¹¹ WHO has recommended the rationale use of PPE for COVID-19 by optimizing the availability of PPE and by minimizing the need for PPE through considering using telemedicine for evaluation in suspected cases.¹² This is expected to minimize the need for these individuals to go to healthcare facilities for evaluation, using physical barriers to reduce the exposures, designate dedicated health workers/teams only for COVID-19 patients care so that they can uses for longer periods of time (extended use of PPE), restrict the number of health workers from entering the rooms of COVID-19 patients if they are not involved in providing direct care, coordinate PPE supply chain management mechanisms through essential national and international supply chain. There is evidence that the utilization of PPE does reduce rates of disease transmission and protects frontline healthcare workers. It is essential that frontline workers understand the aim of PPE and its release part of a system to scale back disease transmission from patients to staff and other patients. It is also important that staff use it appropriately to preserve what could also be limited stocks to ensure that there is sufficient supply for necessary use throughout the epidemic surge.

This study has few notable limitations. First, although the study sample corresponded to different hospitals in different cities of India, the sampling was non-random. The sample is not completely homogeneous, as there are differences in the proportions of professional groups, specialties, experience and much diversity in whether they received trainings or had adequate supply of PPE or not. Second, it is also possibly important to collect information from patients who had suffered from COVID-19 to obtain feedback from a patient perspective. This could offer insights for the health system about how the clinicians and the patient community has understood and employed the PPE during treatment. Third, since this was a cross-sectional study, it is not possible to follow the daily routine and possible work-related limitations and requirements faced by frontline health workers. Lastly, no pilot test of the tools could be conducted due to the quick evolving nature of the COVID-19 pandemic.

Besides being aware of the required PPE, it is also important to know the correct sequence of donning and doffing of PPE. The WHO sequence of donning a facemask is as follows: securing ties or elastic bands at the middle of head and neck, fitting the flexible band to the nose bridge, fit snug to face and below the chin, fit-check respirator.

Conclusions

Healthcare professional were aware of the use of PPE and most of them were using masks and appropriate PPE in their frontline clinical duties. Many of the hospitals did seem to face shortages in supply of PPE. Most of the respondents (as high as 95.38%) have the willingness and interest to receive training to understand the proper method to use and dispose PPE. This study proves that there is a dire need to implement periodic educational interventions and training programs on PPE practices for COVID-19 across all healthcare professions. Faceto-face training, computer simulation, and video training will lead to fewer errors in PPE donning and removal than training delivered through written material or a plain traditional lecture. Conducting periodic webinars for educational intervention for all healthcare students and professionals including non-clinical and administrative staff, paramedical and nursing sub-groups might be a useful and safe tool to make more awareness. In order for healthcare professionals to deliver safe care they need an adequate protection and training in its use. Where employers are failing to provide adequate PPE, safe healthcare cannot be delivered. This aspect poses both a moral and ethical dilemmas to frontline healthcare professionals, thereby creating a sense of inadequacy and under valuation resulting in workforce stress. As healthcare personnel want to ensure their and their patient’s safety, the hospitals and the health system needs to put into place a system that is geared to handle any future pandemics and which aims to safeguard and protect the health of the frontline health workers too. It is important for authorities to provide an efficient supply chain, up-to-date protocols, and pertinent lucid information. This study has highlighted few areas that need to be improved for dealing with further waves of the COVID-19 outbreak and preparations required to handle potential future pandemics and epidemics, especially in a low resource, developing country context.

Conflict of Interest

None.

Acknowledgments

The authors would like to thank all the healthcare workers who voluntarily responded to this study and offered their responses.