key: cord-332815-1w1ikj7q
authors: Zhan, Mingkun; Anders, Robert L.; Lin, Bihua; Zhang, Min; Chen, Xiaosong
title: Lesson Learned from China Regarding Use of Personal Protective Equipment
date: 2020-08-11
journal: Am J Infect Control
DOI: 10.1016/j.ajic.2020.08.007
sha: 
doc_id: 332815
cord_uid: 1w1ikj7q

BACKGROUND: In Wuhan, China, in December 2019, the novel coronavirus was detected. The virus causing COVID-19 was related to a coronavirus named severe acute respiratory syndrome coronavirus (SARS-CoV). The virus caused an epidemic in China and was quickly contained in 2003. Although coming from the same family of viruses and sharing certain transmissibility factors, the local health institutions in China had no experience with this new virus, subsequently named SARS-CoV-2. METHODS: Based on their prior experience with the 2003 SARS epidemic, health authorities in China recognized the need for personal protective equipment (PPE). Existing PPE and protocols were limited and reflected early experience with SARS; however, as additional PPE supplies became available, designated COVID-19 hospitals in Hubei Province adopted the World Health Organization guidelines for Ebola to create a protocol specific for treating patients with COVID-19. RESULTS: This article describes the PPE and protocol for its safe and effective deployment and the implementation of designated hospital units for COVID-19 patients. To date, only two nurses working in China who contracted SARS-CoV-2 have died from COVID-19 in the early period of the epidemic (February 11 and 14, 2020). CONCLUSION: The lessons learned by health care workers in China are shared in the hope of preventing future occupational exposure.

In December 2019, a hospital in Wuhan, Hubei Province, reported several cases of severe unexplained viral pneumonia. The outbreak appeared just before the Spring Festival, one of China's most significant holidays. Millions of people traveled during the holiday. The government scrambled to determine the etiology of the disease. The first patients began seeking medical care with symptoms of respiratory distress, headaches, and fever. Initially, the diagnosis was an upper respiratory infection and treated with standard therapy for influenza-like illness. As the number of infected patients continued to increase rapidly, and the treatments administered did not seem to improve patients' conditions, further investigations were necessary.

There were approximately 110,000 health care workers (HCWs) in Wuhan, which could be called upon to provide care for this emerging epidemic. Quickly the healthcare facilities became overwhelmed with patients. As a result of working long hours under very stressful conditions, there were reported deaths of HCWs. Throughout the epidemic, 42,600 travel nurses and physicians came into Hubei Province, primarily to Wuhan from throughout China to provide relief to the Wuhan HCWs. 1

The paper focuses primarily on the use of PPE to help prevent transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) to HCWs. The aim is to provide more detail regarding level-3 protection protocols used at designated COVID-19 hospitals in Hubei Province to prevent the spread of the virus to HCWs. 

The methods to protect HCWs, designated as level-3 protection in China, included a personal protection protocol for proper use of PPE with coveralls and procedures for changes to the flow of patients and personnel through the designated COVID-19 hospitals. 3 During the Ebola outbreak, the World Health Organization (WHO) had recommended extensive guidance on the protection of HCWs. 4 Biosafety level-3 protection is well known in laboratories that handle dangerous and potentially lethal microbes transmitted by droplets or aerosols. There are many similarities between the recommendations for the protection of laboratory workers and the WHO recommendations for PPE to protect bedside care providers from filovirus disease. After comparing the existing recommendations, all designated COVID-19 hospitals adopted the recommendations endorsed by the WHO for filovirus disease (Ebola). The recommendation ensures protection from head to toe using the coveralls (not the gown), thus minimizing any areas of skin exposure, in combination with the lockdown of designated COVID hospitals. 4

Hospital units treating COVID-19 patients were locked, meaning only personnel wearing the proper protective equipment were allowed entry, and non-COVID-19 patients were not admitted. Most of these units did not have a negative pressure system. Air disinfectant machines that operated 24-hours per day were used in the isolation units and in the transition unit (where removal of the PPE occurred).

Upon arrival at the hospital, nursing and physician staff entered the clean areas through a staff-dedicated hallway; patients arrived through another patient-dedicated entrance.

Additionally, there were separate elevators for staff and patients. The temperature of HCWs was measured on entrance. HCWs with a temperature of more than 37.2 ℃ (99 °F) were not allowed to enter the hallway.

In the clean areas, staff would begin following a standardized procedure for donning PPE. The WHO Ebola PPE protocol includes a first layer of a scrub suit, followed by rubber boots (which were too cumbersome for work in the isolation unit) or closed-toe shoes with shoe covers, two layers of gloves, coverall, face mask, face shield/goggles, a head and neck covering, a surgical bonnet covering the neck and sides of the head or a hood, and a disposable waterproof apron. 5 The adopted COVID-19 protocol included a hospital-provided scrub suit, complete covering of dorsum of the foot and ankles with socks covered by plastic wrap and closed shoes with two layers of boot covers (substituted for the heavy rubber boots), three layers of gloves, a coverall, N95 face mask, surgical mask, face shield/goggles, hood with two layers of head covering, and a disposable waterproof surgical gown. The rubber boots were available for staff to wear from the transition unit to home or hotel.

Before starting the 4-hour shift (primarily for nurses) and a 6-hour shift (physicians), the staff arrived in the clean areas where a one-way hall led to the locked isolation unit. Most of medical and nursing staff wore diapers instead of leaving the unit to use the bathroom. There are various approaches to donning and removing the PPE; posters developed by the WHO were available to staff for reference. 5 Using 0.5% w/v isopropyl alcohol 75% v/v is the first step in performing hand hygiene. A total of 17 steps were involved in donning the PPE as described in the adopted protocol above.

At the end of a four-or six-hours shift, staff moved to a transition unit, located outside of the locked isolation unit where the PPE removal and decontamination process began. The removal of PPE is a time with a high risk of contamination. The process started with washing the gloved hands with a solution of isopropyl alcohol; hand sanitizing is also recommended after the removal of each piece of PPE. When taking off the surgical gown and coveralls, ensure the front is folded inward to minimize the possibility of contamination. It is recommended the gloves be removed during this step and turned inward as well. All contaminated PPE must be disposed of properly. After removal of the N95 mask, it is recommended a surgical facemask be worn.

After removal of the PPE, the staff then proceeds to the clean unit. The steps in Table 1 are our recommendations for additional decontamination. The WHO protocol is silent on the steps to be taken after the PPE is removed. Each agency needs to adapt the process to meet their goals for staff safety. Table 1 illustrates only one method, which was the method used in COVID-19 facilities in Hubei Province.  Shower and change to clean clothes and rubber boots.

 Arrive at hotel/home, clean boots with disinfectant and remove them (leave them at the designated area in the lobby of the hotel), and change to slippers.

 Remove and leave the jacket provided by the hospital at the designated area of the hotel lobby and change to the coat (the coat was sprayed with chlorine disinfectant every 4 hours).  Leave slippers outside of the individual room or home and change to house slippers.  Perform hand hygiene with a solution of isopropyl alcohol, then remove the coat and leave in the area near the door to the room or home.

 Take a full-body bath with soap and move to a clean area of the room to change to a different pair of slippers.

 Clean the nasal cavity and ear canal with an alcohol swab.

 Use mouth wash before eating. In Wuhan, the entire process of transiting from the hotel (for travel nurses and physicians), donning PPE, working their shift, removing the PPE, and returning home could take up to ten hours. Thus, the staff had extensive time spent in preparing, providing care, or decontaminating before going home. Isolation was encouraged to continue at the hotel or home to protect others from potential infection.

As early as January 23, 2020, a total of 176 members of the HCWs were clinically or laboratory diagnosed with COVID-19. 6 Since that time, with the implementation of the level-3 protection protocols and the implementation of COVID-designated hospitals, the number of HCWs diagnosed with COVID-19 has decreased. 6 According to the Chinese Red Cross Foundation (CRCF), as of June 2, 2020, a total of 3,623 HCWs have been diagnosed with laboratory-confirmed or clinically confirmed COVID-19 throughout mainland China. A total of 31 HCWs had died from COVID-19. 6 Only two nurses were infected with SARS-CoV-2 while performing their duties and then died from COVID-19. 7, 8 No other deaths from COVID-19 of nurses who had worked in mainland China during the epidemic have been reported.

In the USA as of April 9, 2020, there were 9,282 HCW with COVID-19 and of these 73% were women. 9 Investigators noted that the number of cases among HCWs in the study were likely an underestimation as healthcare status was missing for 84% of patients reported nationwide. As of April 8, 2020, WHO had been recording 22,073 cases of COVID-19 among HCWs from 52 countries. Nevertheless, there is currently no formal documentation of HCWs COVID-19 infections to the WHO. The true number of COVID-19 HCWs infections worldwide are potentially underrepresented. 10 Liu and colleagues in a cross-sectional study of four hospitals in Wuhan, China found that of 420 travel HCWs caring for COVID-19, none were infected with SARS-CoV-2. 11 The authors concluded the use of effective PPE is contributed to there being no infections among those HCWs. Their findings are consistent with the support recommendations in this study.

The experience in designated COVID-19 hospitals demonstrates the evolution of how HCWs reacted to COVID-19 in Wuhan and Hubei Province. The lack of adequate PPE was a contributor to the number of HCWs initially infected with SARs-CoV-2. Many asymptomatic patients were seen for non-COVID-related conditions unknowingly exposed to some HCWs in the outpatient clinics, which also contributed to the infection rate.

The PPE protocols implemented in designated COVID-19 hospitals is thought to have Approximately 90% of the 28,600 travel nurses were under age 40, and 25,300 travel nurses were women. 12 The nurses, for the most part, did not have underlying medical issues that might place them at risk. 10 Younger age and gender has proven in some way to be protective. 13, 14 A Cochrane Systematic Review of PPE supports the importance of putting on the PPE correctly, that it may be uncomfortable to wear, and there is a risk of contamination with removing it. 15, 16 Before implementing the PPE protocols, nurses may have placed a greater emphasis on washing their hands, using gloves, and wearing a face mask and hair covering more frequently than other HCWs (M. Zhan, and B. Lin, personal communication May 2, 2020). However, the rapid adoption of a level-3 protection and careful use of PPE including coveralls was most likely a significant factor in protecting the nurses and other HCWs from infection. (See Table 2 ) 6 Most of the early infections occurred before the adoption of level-3 protection.

The report provides useful insight for developing future strategies to deal with infectious disease pandemics. The need for continued preparedness is paramount. Policymakers must assume that there will be another epidemic. It may be the SARS-COV-2 reemerging in the fall of 2020 or perhaps another viral agent. Public health officials working in collaboration with federal, state, and local health departments must plan for the next epidemic.

There needs to be a federal (national) and provisional (state) stockpile of PPE including coveralls and other necessary supplies required to care for patients with infectious diseases.

There needs to be a method of ensuring that supplies are kept secure, and as they become outdated are rotated with new ones. The need for planning and funding for such including the necessary equipment and supplies is critical. Failure to plan may mean additional lives lost.

Other hospital units beyond the ones used in this pandemic also need to be identified. Providing 

The current rate of infection has dramatically declined. The environmental controls limiting social contact and mobility have helped to create a safer environment. Readily available testing for suspected individuals with COVID-19 has helped to identify those who may be at risk quickly. As a result of the level-3 protection protocols combined with admitting patients to only COVID-19 designated hospitals, the number of HCWs infected declined significantly since mid-February 2020. Our experience may help other health systems better cope with outbreaks of the highly contagious SARS-CoV-2.

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We want to acknowledge all state, local, and territorial health departments and personnel in China, working in and supporting the designated COVID-19 hospitals in China. A special thanks to Charon A. Pierson, Ph.D., GNP, FAAN, FAANP, Editor Emeritus, Journal of the American Association of Nurse Practitioners for her medical editing support.
