Personal Protective Equipment: Challenges and Strategies to Combat COVID-19 in India: A Narrative Review

Abstract

The current outbreak of the coronavirus disease (COVID-19) has become a pandemic. All COVID-19-affected countries in the world are implementing containment interventions and trying their best to fight against the disease to halt the further spread of the infection and to reduce mortality. The public health workforce and healthcare staff in clinical settings are playing a crucial role in the early detection of cases, contact tracing and treatment of patients. The availability of personal protective equipment (PPE) and their consistent, proper use by healthcare providers and public health professionals is a crucial factor in combating any infectious disease in a crisis. The requirement of PPE has exponentially increased, as more and more countries are experiencing the COVID-19 pandemic. The rapid spread of the pandemic has created a temporary shortage of PPE in many countries, including India. The lack of PPE has affected the morale of healthcare workers (HCWs) and other frontline warriors in fighting the coronavirus disease, as more than 22,000 health workers in 56 countries have suffered from COVID-19. Some of them have succumbed to it across all countries, including India (WHO). We have reviewed the available literature to understand the challenges in ensuring adequate availability and consistent use of PPE and the strategies for the rational use of PPE in India. Our study reveals that India has responded swiftly to enhance the accessibility of PPE and put in place strategies for the judicious use of PPE to reduce the incidence of the COVID-19 infection to a bare minimum in healthcare settings. In the present article, we report the current status of COVID-19 among HCWs. We have reviewed the challenges and the surge strategies adopted by India to produce or procure good-quality PPE and supply it to all service delivery points in adequate quantities.

Keywords

Personal protective equipment PPE coronavirus COVID-19 healthcare worker India

Background

The last-century pandemic of the Spanish flu between January 1918 and December 1920 infected 500 million people. It claimed 17 million to 50 million lives (The Economic Times, 2020e). India bore the most considerable burden of the Spanish flu then, as 6 per cent of the country’s population lost their life (CDC, 2019; Khan & Patrick, 2016). Today, the world is facing an ongoing coronavirus infection, which has been declared a public health emergency and pandemic by the World Health Organization (WHO). The threat of the COVID-19 pandemic is no less than that of the Spanish flu pandemic experienced by the world, and it threatens to surpass the Spanish flu pandemic by the sheer force of its speed of spread and impact on the society. In a virtual briefing from Geneva held on 13 April 2020, the Executive Director, WHO, said that the coronavirus disease (COVID-19) is 10 times deadlier than the H1N1 pandemic of 2009 (The Economic Times, 2020c). The current outbreak of coronavirus originated in Wuhan, China, in December 2019. Initially, China reported a cluster of pneumonia-like cases in Wuhan city. When traced retrospectively, it was found that it is a new viral infection resulting from human-to-human transmission in Hubei province (Zhu et al., 2020).

As on 19 April 2020, China had reported 84,223 confirmed cases and 4,642 deaths and also reported that more than 3,000 healthcare workers (HCWs) have suffered from this infection, prompting a lockdown for more than 10 weeks (The Economic Times, 2020a; Wang et al., 2020; WHO, 2020i; Wu & McGoogan, 2020). The battle seems to have spread to every nook and corner of the world within a few months. Soon, the WHO officially declared it a public health emergency of international concern and named it novel coronavirus disease 2019 (nCOVID-19) (WHO, 2020c). ‘Globally, as of 2:00 am CEST, 19 April 2020, there have been 2,245,872 confirmed cases of COVID-19, including 152,707 deaths, reported to WHO’ (WHO, 2020i). The Institute for Health Metrics and Evaluation (IHME) estimated that 81,114 (95% uncertainty interval 38,242 to 162,106) deaths can occur in the United States alone due to COVID-19 over the next 4 months (IHME, 2020).

India reported the first case of COVID-19 in Kerala on 30 January 2020, and within a couple of weeks, COVID-19 spread to 27 states and 7 union territories in India (WHO, 2020d). India adopted the disease containment strategies as per the WHO guidelines to fight against COVID-19 and implemented an early lockdown for 21 days on 25 March 2020, when the total confirmed cases were 550 only. India started early identification of confirmed cases, isolation of all such cases and screening of all suspects as specified under the national guidelines (WHO, 2020a). The Indian Council for Medical Research (ICMR), a nodal agency for health research, has successfully tested more than 300,000 samples as on 16 April 2020 (ICMR, 2020). Under the national guidelines for combatting the rapidly spreading COVID-19 in the country, local health authorities work in close collaboration with administrative machinery of the districts/ states to innovate local/specific strategies. One such example is the strategy adopted in Bhilwara district, Rajasthan, where the COVID-19 outbreak was proactively tackled. This strategy is referred to as Bhilwara model; it not only contained the spread of the disease but resulted in the complete recovery of all patients, with only two deaths (The Economic Times, 2020b; The Print, 2020).

The spread of COVID-19 is localised to a few urban clusters in each of the affected states in India. It is directly related to the introduction of the disease with returning international passengers from the countries where the COVID-19 pandemic was at the stage of community transmission. Subsequently, the disease spread to close contacts of these positive cases. The elderly and individuals with chronic underlying conditions are prone to infection and severe disease resulting in higher case fatality rates. Still, there is no definitive evidence of community transmission in India, and largely, the disease is confined to few clusters in each of the affected states. The early nation-wide lockdown and swift containment measures have resulted in a slowdown of the spread of the disease in India. This is evident from the total confirmed cases of COVID-19 reported and the declining growth rate of new cases of COVID-19.

Till date, there is no proven vaccine, and little evidence is available on the effectiveness of potential therapeutic agents (WHO, 2020e) against COVID-19. The entire population of a country is susceptible to COVID-19, as there is no pre-existing immunity. A review by Higgins et al. (2013) concluded that the Bacillus Calmette–Guérin (BCG) vaccine has potential benefits against any pathogen, including viruses, when given in the first year of life (Higgins, 2013). India has a policy of universal BCG vaccination at birth. It is reported that universal childhood BCG vaccination may explain the slow spread of COVID-19 in India and the low number of confirmed cases of COVID-19 (Arts et al., 2018; Vrieze, 2020).

Globally, HCWs face a risk of infection while giving care to suspected or confirmed cases and engaging in laboratory testing. Spain has reported around 15,000 HCWs affected by COVID-19, which is the highest in the world, followed by Italy, where 10 per cent of the confirmed cases are of HCWs (Time, 2020). According to the WHO, COVID-19 has infected 22,073 health workers in 56 countries as of 8 April 2020. Even in India, till date, more than 400 healthcare professionals of various public and private healthcare facilities have been quarantined, based on either suspicion or confirmation of being exposed to COVID-19 patients (Financial Express, 2020; Times of India, 2020b). It is evident from previous studies that a good-quality personal protective equipment (PPE) is an effective and efficient way to keep HCWs safe (Honda & Iwata, 2016; WHO, 2018b). But there are reports of a shortage of PPE kits, creating panic among HCWs, especially among those in the frontline (Al Jazeera, 2020a). These reports prompted us to plan this review to assess the status of COVID-19 infection among HCWs and the challenges and strategies to enhance the availability and rational use of PPE to combat COVID-19.

Methodology

For this rapid narrative review, we searched the online databases of PubMed, Scopus and Google Scholar. We searched for online grey literature from the webpages of the WHO, Centre for Disease Control (CDC), Johns Hopkins School of Public Health (JHSPH), Novel Coronavirus Information Centre of Elsevier, COVID-19 Open Research Dataset (CORD-19) of Semantic Scholar, COVID-19 updates and information by EBSCO, Ministry of Health and Family Welfare, Government of India (MoHFW-GoI) and ICMR (EBSCO, 2020; Elsevier, 2020; MoHFW-Govt. of India, 2020b; Semantic Scholar, 2020). We also used the COVID-19 emergency dashboards of the WHO, IHME and Johns Hopkins University. For the latest updates, our team referred to the established online newspapers of the regional and national levels.

Findings and Discussion

The Situation of the COVID-19 Pandemic in India

As on 19 April 2020, India has recorded 17,265 total infected cases and 543 deaths spread over 32 states and UTs. Of the total COVID-19-infected cases, 2,546 patients (14.75%) have recovered from the infection. The overall case fatality rate is 3.14 per cent (MoHFW-Govt. of India, 2020b).

COVID-19 infection among doctors, nurses and other field-level functionaries involved in various duties combating the disease in India has been reported. Two doctors died from COVID-19 in Madhya Pradesh, while several doctors and nurses have been reported with infection from Rajasthan, Maharashtra and Delhi. The COVID-19 infection has been reported among the police and army as well (Deccan Herald, 2020; India News, 2020; The Hindu, 2020; Today News, 2020).

Status of PPE Availability and Its Use

Shortage of PPE is reported worldwide due to rise in demand, panic-buying and irrational use (WHO, 2020g). The global shortage of PPE was experienced during the Ebola outbreak of 2014–2016 in West Africa, which resulted in a high number of infected HCWs (900 infected, 500 deaths). A WHO report on the HCWs of Ebola infections in Guinea, Liberia and Sierra Leone from January 2014 through March 2015 concluded that HCWs had a 21 to 32 times greater risk of contracting Ebola due to multiple infection prevention and control failures, including lack of PPE (WHO, 2015). This report highlights the importance of access and availability of PPE at the right place and right time and of the right quality and right quantity. It also emphasises prioritising PPE use by HCWs as per PPE guidelines in such situations.

In the current rapidly evolving pandemic of COVID-19 in India, all states and UTs are reporting the disease. The COVID-19 pandemic has resulted in a sudden increase in demand for PPE in all states (Financial Express, 2020). Further spread of the COVID-19 infection in the country in the coming days and weeks may further enhance the demand for PPE. It has not given decision-makers and hospital managers enough time to procure and distribute PPE in adequate quantity.

In such exceptional situations, strategies for increasing procurement and local manufacturing capacities of PPE are warranted, with adequate planning. Government of India (GoI) has promptly taken appropriate and early steps to deal with the increased demand for PPE. GoI has placed orders to import good-quality PPE conforming to standards and simultaneously boosted internal capacity to manufacture PPE in large quantity. The Defence Research and Development Organization (DRDO), India, has developed low-cost and high-volume PPE at a large scale (The Economic Times, 2020d). Many private sector units also started manufacturing PPE to meet the demand (MoHFW).

Challenges in Augmenting Access to PPE

Commonly, PPE include items such as gloves, safety glasses and shoe covers, earplugs or muffs, hard hats, face cover, masks or respirators, coveralls, vests and full bodysuits. The guidelines issued by GoI on the rational use of PPE kits for COVID-19 focuses on using gloves, coverall or gowns, goggles, N95 masks, shoe covers, triple-layer medical masks and headcovers (MoHFW-Govt. of India, 2020d; Occupational Safety and Health Administration, 2020), based on the risk assessment.

During the COVID-19 pandemic, access to PPE is one of the key concerns for HCWs’ safety. Certainly, the safety of HCWs and other functionaries performing different roles in the containment of COVID-19 pandemic is always a priority. The PPE shortage resulted due to low buffer stock and lack of preparedness and processes to quickly procure PPE at facilities in situations of unexpected increase in demand. Panic-buying by the general public also contributed to the shortage.

The shortage of PPE posed a challenge, as it is an important cause of stress among HCWs. Doctors and nurses must use proper PPE while examining patients in the triage area or treating patients in an inpatient facility or intensive care unit (ICU). Public HCWs performing field surveys for active surveillance in a lockdown situation confounds the challenges faced due to long working hours and non-availability or shortage of good-quality PPE. Misuse or inappropriate use of PPE added to the shortage.

The COVID-19 virus is highly contagious. But lack of proper scientific evidence relating to the nature and virulence of SARS-CoV-2 (COVID-19) creates uncertainty among HCWs and programme managers in the context of the crisis. A study by Seongman et al. (2020) contradicted the use of surgical and cotton masks as protective measures for patients with suspected or confirmed COVID-19 to prevent transmission (Seongman et al., 2020). The guidelines on the use of PPE by health workers recommend that a full set of PPE is essential in high-risk situations, while in other situations, different items such as a medical mask and gloves are sufficient.

Other common challenges observed in the use of PPE were the selection of appropriate PPE while dealing with COVID-19 patients or dealing with a suspected infected person. The situation is further compounded by the factors related to the availability of PPE, usage guidelines, skills of health workers regarding the use of PPE and practices of safe disposal.

Availability of PPE

The health system preparedness for the health emergency of the pandemic seems inadequate. The spread of COVID-19 in the country in a short period of 70 days has created an unprecedented demand for PPE by hospitals, healthcare institutions, healthcare professionals, public HCWs and other allied functionaries in the field. The increased demand is compounded by the geographical spread of cases across the country, leading to a logistics nightmare. The lack of availability of PPE could be understood by the fact that hospitals had low levels of buffer stock of PPE and the demand surged suddenly. Hence, in some instances, the HCWs attempted other plausible options like the use of helmets, plastic bags and raincoats as protective gear amid PPE shortage (Lee et al., 2020; The Hindu Business Line, 2020). The press release on 30 March 2020 by the MoHFW stated the current availability of 334,000 PPE in various hospitals across the country (MoHFW-Govt. of India, 2020c) and that it was looking for around 3 million PPE kits through overseas procurement. Still, the estimated requirement is close to 15 million units (Times of India, 2020a). GoI has placed import orders for PPE approved by MoHFW (India Today, 2020). According to a recent report, around 63,000 Chinese-manufactured PPE did not meet the Indian quality standards (Telangana Today, 2020) and were returned.

Usage Guidelines

The CDC and WHO guidelines on COVID-19 for emergency service providers mention that healthcare providers must adhere to the guidelines for the use of PPE (CDC, 2016; WHO, 2020b), whereas the MoHFW guidelines focus on appropriate selection and use of PPE based on the risk of infection to an individual. The MoHFW-GoI guidelines on PPE use recommend health desk persons and temperature-recording station officers to use triple-layer medical masks and gloves in low-risk situations. In moderate-risk situations, they recommend isolation area workers who are not attending to patients or suspects and sanitary staff to use N95 masks and gloves. In high-risk situations, those directly attending to the patients/suspects and ICU and laboratory workers are recommended to use the full complement of PPE (MoHFW, 2020b). Nevertheless, efficient use of PPE by health workers and other functionaries requires intense skill-based training and experience.

Indian HCWs have a limited experience of using PPE for the containment and treatment of airborne infections such as SARS in 2003 and isolated incidents like the outbreak of the Nipah virus encephalitis in Kerala (WHO, 2018a). Health workers should be skilled in the selection of appropriate PPE based on risk assessment, and correct and consistent use of PPE is essential for the effectiveness of PPE in preventing infections. The health workforce is also required to follow the universal precaution of infection control. The rapid transmission of COVID-19 warrants organising an education programme for training health workers on the correct and consistent use of PPE and on adherence to national guidelines on PPE use. Social media platforms like WhatsApp, Zoom app and other institutional online platforms are used for providing such education programmes. Similar programmes have been organised by Infection Control and Prevention (IPC) to generate awareness on healthcare associate infections on COVID-19 and its prevention (IPC, 2020) and by the WHO on water, sanitation, hygiene and waste management regarding COVID-19 (WHO, 2020h). Still, more capacity building efforts for the donning and doffing of PPE and for following infection control protocols of PPE are required, and additional efforts at different levels by the health department might be necessary (MoHFW-Govt. of India, 2020a).

Safe Disposal of Used PPE Items

Disposal of PPE waste is again a challenge. There are some newspaper reports of the collection of discarded single-use items of PPE by some people for re-circulating after cleaning and repackaging (Indian Today, 2020). As COVID-19 is a highly infectious disease, a small mistake while handling or disposing of used PPE items may lead to a further spread of the disease in the community or among persons negligent in handling PPE waste.

Safe and proper disposal of used PPE is recommended in GoI’s biomedical waste (BMW) management rules, 2016, and the Central Pollution Control Board (CPCB) guidelines (Central Pollution Control Board, 2020; MoHFW-Govt. of India & Central Pollution Control Board, 2016). Under these BMW rules, PPE items should be disposed of in yellow, non-chlorinated plastic bags and be considered as infectious waste. The BMW guidelines suggest the use of double-layered bags for ensuring leak-proof collection and transportation. These bags or containers should be adequately labelled as COVID-19 waste (Quartz India, 2020). Additionally, precautions would be required for the dedicated transport vehicles via their sanitisation after each trip. The workers involved in the handling and collection of biomedical waste must use proper PPE, including three-layer masks, splash-proof aprons or gowns, nitrile gloves, gumboots and safety goggles.

Strategies for Ensuring Adequate Supply and Rational Use of PPE

‘Necessity is the mother of invention’. The rapid spread of the COVID-19 infection resulted in the increased demand for and utilisation of PPE by HCWs in discharging different duties while caring for the community at risk of COVID-19. However, lack of technical troubleshooting capacity and tolerance of PPE in a stressed environment for long hours are a couple of the known contributory factors leading to the faltering in adhering to the guidelines of appropriate PPE use. Fortunately, GoI and institutions have taken quick steps towards correcting the unmet demand- and supply-side issues. We should still be open for other possible options to mitigate this challenge and seek help at the individual or organisational level. While everyone was looking for new ways, we came across a few useful strategies during our literature review. Table 1 summarises the strategies for enhancing the supplies of PPE and promoting rational use (CDC, 2020a, 2020b; Koehler & Rule, 2020; The Joint Commission, 2020; WHO, 2020g).

Beyond increasing the supply, a crucial role of the government is to coordinate efforts to ensure that the areas hardest hit at any given time receive the required PPE supplies on time and in adequate quantity. The state governments and healthcare managers are currently competing for resources, and those resources are not necessarily being distributed based on an actual assessment of need.

Table 1.

Strategies to Increase Availability and Rational Use of PPE in Combating COVID-19

Increasing the manufacturing

Call private sector industries and government unites to increase manufacturing to meet rising global demand.

Increasing the lifeline of available PPE

Extending the lifeline of N95 mask.

Permit reuse of respirators by one staff member for multiple encounters with different patients.

Reuse of intact PPE that performs adequately for healthcare delivery beyond the manufacturer’s shelf life.

Rational use of PPEs

Selection of appropriate PPE based on service delivery activities and assessment of risk of infection. Including reserving sterile gowns and gloves for urgent sterile patient procedures, such as surgery, and reserving respirators for aerosol-generating procedures and patient care with airborne transmitted disease risks, like tuberculosis, measles and varicella.

Alternative approaches

Use respirators that are similar to NIOSH-approved respirators but approved under standards used in other countries.

Redesigning of PPE, that is, Homemade cotton mouth masks for the general population.

Dealing with negative information

Enhanced monitoring for negative impact (e.g., increased reports of exposure or infection) should be instituted. They may lead to unnecessary stockout from the market and may create anxiety among the population.

Appropriate training

Appropriate training of healthcare workers in donning and doffing of PPE as it has been seen that risk of getting infected increases while removal of PPE.

Burn rate calculation

Institution/facility level burn rate for PPEs should be calculated to deal with unnecessary stockout situation. A burn rate calculator facilitated by the CDC could be very useful.

Source: CDC (2020b, 2020a), Koehler and Rule (2020), The Joint Commission (2020) and WHO (2020h).

Recommendation on the Reuse of PPE

The demand-and-supply balance has been adversely affected by the COVID-19 pandemic, and the surge in demand cannot be fulfilled by the limited indigenous manufacturing capacity. Developed countries were the worst affected by the PPE supply gap, and health professionals are demanding PPE like never before (Al Jazeera, 2020b). The MoHFW-GoI guidelines and other similar guidelines by the CDC and WHO permit the extended use and limited reuse of N95 masks. However, these guidelines emphasise judicious utilisation of N95 respirators by healthcare professionals in a high-risk area, maximising the usage and using other respirators to compensate for the supply gap (American Veterinary Medical Association, 2020; CDC, 2020c). As per the WHO, the use of a mask by asymptomatic individuals is not recommended. This unnecessary purchase by people and the hoarding of the medical mask, the N95 mask, and gloves may have contributed to the shortage and unnecessary incremental increase in the cost of PPE. (WHO, 2020f).

The All India Institute of Medical Science (AIIMS), New Delhi, has released guidelines on the reuse of PPE, citing fast-depleting stocks of PPE. The guidelines recommend that decontamination of PPE should be considered as an unusual step, as it degrades performance, especiallythat of respirator masks. However, reuse provides another solution by extending the existing supplies. According to the AIIMS guidelines, overalls and N95 masks can be decontaminated using a double dilution of 11 per cent hydrogen peroxide vapours in a sealed room, while face shields and goggles can be sterilised using 0.5 per cent sodium hypochlorite solution and 70 per cent alcohol (AIIMS, 2020).

The National Institute for Occupational Safety and Health provide guidance on the extended use and limited reuse of N95 masks in healthcare settings in specific situations to conserve supplies while safeguarding health workers (CDC, 2020c).

Conclusion

In India, we are today fortunate that the shortage of PPE has not become a crisis. Still, we have to be ready with all available options to overcome this challenging situation of increased demand for PPE leading to the sudden acute shortage, by adopting new ways and innovations to combat this unforeseen situation. We can prepare our workforce for different levels of public health emergencies through ongoing capacity-building training programmes. Also, learnings while overcoming these challenges should make us ponder over preparing our healthcare infrastructure for future pandemics by leveraging the strengths of the public and private sectors and instituting a regular audit by a recognised, quality body like the National Accreditation Board for Hospitals & Healthcare Providers (NABH) on optimising the usage of quality PPE for our healthcare professionals.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship and/or publication of this article: None.

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