Personal protective equipment (PPE)

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INTRODUCTION

Having studied microbiology, worked in a security laboratory with cultivation and experiments with  Salmonella typhimurium bacteria at Klinisk Bakteriologi in Gòteborg under the leadership of prof Lars Edebo and now living in Italy, I wondered how Italian physicians and other healthcare personnel (HCP) protect themselves from airborn infections like Corona virus.

As you probably know, many Italian family doctors have died.

I read about airborn infection protections in different sites like 

This is by no mean a scientific research as I have no other sources than newspaper photos. So it is to be seen as a basic introduction to the issue. 

I got answer from HCP in Sweden and Switzerland.

A study about “Inventory of isolation capabilities and recommendations for appropriate isolation ” with emphasis on Mediterranean Sea area,  has been done by the EuroNHID Working Group and published August 2018 ( www.sciencedirect.com )

I use screenshots from this doc for Bulgaria, France, Germany and Italy.

INDEX

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Glossary

BFE (Bacteria Filtration Efficacy)

This has been studied in Brazil for surgical masks.

Probably a study of protection for the person who wear the mask.

(Source:  www.scielo.br )

highly infectious disease and list of agents / diseases

(Source : www.sciencedirect.com  )

A highly infectious disease

The diseases/agents listed as highly infectious diseases

  • Is transmissible from person to person.
  • Causes life-threatening illness.
  • Presents a serious hazard in healthcare settings and in the community, requiring specific control measures.
  • Human-to-human transmissible viral haemorrhagic fevers (Ebola, Marburg, Crimean Congo, Lassa and South American haemorrhagic fever; Junin, Machupo, Sabia and Guanarito viruses).
  • SARS-CoV, MERS-CoV.
  • Emerging highly pathogenic strains of influenza virus.
  • Smallpox and other orthopoxvirus infections (e.g. monkeypox, but excluding vaccinia virus).
  • Extremely drug-resistant tuberculosis.

Bioaerosols and AGP

An airborne dispersion of particles containing whole or parts of biological entities, such as bacteria, viruses, dust mites, fungal hyphae, or fungal spores. Such aerosols usually consist of a mixture of mono-dispersed and aggregate cells, spores or viruses, carried by other materials, such as respiratory secretions and/or inert particles. Infectious bioaerosols (i.e., those that contain biological agents capable of causing an infectious disease) can be generated from human sources (e.g., expulsion from the respiratory tract during coughing, sneezing, talking or singing; during suctioning or wound irrigation), wet environmental sources (e.g., HVAC and cooling tower water with Legionella) or dry sources (e.g., construction dust with spores produced by Aspergillus spp.). Bioaerosols include large respiratory droplets and small droplet nuclei (Cole EC. AJIC 1998;26: 453-64). Read more at 

www.sciencedirect.com

As I understand bioaerosol concentration should be kept minimum with e.g. negative pressure rooms and few patients per area.

https://www.cdc.gov/infectioncontrol/guidelines/isolation/glossary.html 

 Public Health England (PHE) guidelines  writes that !The following procedures are currently considered to be potentially infectious Aerosol generating procedures (AGP) for COVID-19:

  • intubation, extubation and related procedures, for example, manual ventilation and open suctioning of the respiratory tract (including the upper respiratory tract)
  • tracheotomy or tracheostomy procedures (insertion or open suctioning or removal)
  • bronchoscopy and upper ENT airway procedures that involve suctioning
  • upper gastro-intestinal endoscopy where there is open suctioning of the upper respiratory tract
  • surgery and post mortem procedures involving high-speed devices
  • some dental procedures (for example, high-speed drilling)
  • non-invasive ventilation (NIV); Bi-level Positive Airway Pressure Ventilation (BiPAP) and Continuous Positive Airway Pressure Ventilation (CPAP)
  • High Frequency Oscillatory Ventilation (HFOV)
  • induction of sputum
  • high flow nasal oxygen (HFNO)

Airborne infection isolation room (AIIR)

Formerly, negative pressure isolation room, an AIIR is a single-occupancy patient-care room used to isolate persons with a suspected or confirmed airborne infectious disease. Environmental factors are controlled in AIIRs to minimize the transmission of infectious agents that are usually transmitted from person to person by droplet nuclei associated with coughing or aerosolization of contaminated fluids.

AIIRs should provide

negative pressure in the room (so that air flows under the door gap into the room);

EuroNHID shares a few solutions in its report.

 www.ama-assn.org says among others:

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Airborn infection protection strategy

  • www.cdc.gov says among others:
  • place patients with suspected or confirmed COVID-19 in private rooms with the door closed…
  • Reserve AIIRs … for care of patients with pathogens transmitted by the airborne route (e.g., tuberculosis, measles, varicella).
  • Facemasks, if available, should be reserved for HCP.
  • For patients, a cloth face covering may be appropriate.

Masks

( Source:   www.iltempo.it  )

Italian Il tempo published this table with respiration data for different masks.

Researchers in Canada randomly assigned 446 nurses to wear N95 or surgical masks during a few months of cold and flu seasons (September to December). Then they tracked how many got the flu or a cold. (Source: smartairfilters.com )

Twenty percent of nurses wearing surgical masks got sick versus 22% wearing N95 masks.Twenty percent of nurses wearing surgical masks got sick versus 22% wearing N95 masks. (Source: smartairfilters.com )

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Bulgaria

NO HLIU

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England

 Clinicians in PPE (Source:  www.theguardian.com )

As you can see in the photo they use face mask and mask

 Public Health England (PHE) guidelines stipulating that full-length waterproof surgical gowns, designed to stop coronavirus droplets getting into someone’s mouth or nose, should be worn for all high-risk hospital procedures. (Source:  www.theguardian.com )

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France

5 HLIU

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Germany

6 HLIU

 

 

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Italy

There seems to be one HLIU in Rome (Spallanzani) and one in Milan.

Cotugno di Napoli

This hospital had no infected HCP April 23. “Cotugno in Naples, a “model” hospital for Covid 19? To date, zero contagion among staff. Interview with Dg Di Mauro”

Read more at www.quotidianosanita.it

(Source: www.nytimes.com/2020/03/12 )

 

(Source: Repubblica Rome edition page 6 20200416)

(Source: Repubblica Rome edition page 6 20200416)

Italy has a well known virologist, Ilaria Capua. Several interviews are available at www.la7.it/

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Sweden

(Source: Swedish television news Rapport )

I asked a Swedish HCP about  this photo and got this answer (translated from Swedish to English):

The protective mask that is in the photos I know they use at the infection clinic in Linköping.
At the infection clinic there are preparedness for high-risk care, which means that they have preparedness to care for, for example, viral hemorrhagic fever such as Ebola and Lassa.
I think they bought these protective masks because of their high-risk preparedness.
So this protective equipment is not standard when working with Covid patients in Sweden!
But it is very practical, because they do not become dependent on access to respiratory protection, mouth protection or visor / goggles, but can instead wash off their protective equipment and can use it several times!
I believe that all infection departments in the Swedish hospitals have rooms with negative air pressure (ed. AIIR).
I work at the infection clinic at the Östra Sjukhuset (ed. Göteborg area hospital.) and we have this in every room, it is needed to care for patients with airborne infection.

There has been a lot of discussion recently in Sweden about what type of protective equipment to wear. What applies to us at the infection clinic at theÖstra Sjukhuset is:

  • – visor or goggles
  • respiratory protection FFP2 or FFP3 if there is a risk of aerosol.
  • Otherwise, regular oral protection (the kind that dentists sometimes use).
  • apron (sometimes long-sleeved)
  • gloves

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Switzerland

I got this answer from a doctor in Switzerland:

“I can answer you based on what we do in my hospital, not for all of Switzerland. We have

  • ffp2 and ffp3
  • masks as protection,
  • waterproof goggles
  • and gowns
  • And of course gloves.

They are all detached pieces, there are no overalls, or visors that cover everything as you see in Italy (those called diving suits) Ideally patients should be isolated in negative pressure rooms, but this is not achievable during a pandemic of this size. We have some negative pressure rooms (they are operating rooms converted into resuscitation rooms). Each houses two intubated and ventilated patients, but they are not the majority of patients.

Rather, cohort isolation is practiced, i.e. all patients with covid in areas separate from non-covid ones, but without any separation between positive covid patients. So patients are not alone in closed rooms.”

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abbreviations

  • healthcare personnel HCP
  • Highly Infectious Diseases HID
  • High level isolation Units. HLIU

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conclusion

 


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