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      Personal protective equipment in the response to the SARS-CoV-2 outbreak - A letter to the editor on “World Health Organization declares global emergency: A review of the 2019 novel coronavirus (COVID-19)” (Int J Surg 2020; 76:71-6)

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          Abstract

          Dear Editor, We read with great interest the article by Sohrabi et al. regarding the current 2019 novel coronavirus, SARS-CoV-2 outbreak. The article presented the timeline of the initial outbreak and response, describing key aspects such as management, transmission and symptoms[1]. In this letter, we provide a detailed update on the supply of personal protective equipment (PPE) in the United Kingdom (UK), highlighting key statistics and updated PPE guidelines on surgical procedures. We provide comparisons to World Health Organisation (WHO) guidelines and describe recent innovations aiming to reduce hospital SARS-CoV-2 spread. SARS-CoV-2 has been shown to spread in human to human contact through aerosol droplets. Therefore, healthcare staff are at an increased risk of infection, especially during aerosol generating procedures (AGPs) including intubation, a procedure essential in maintaining ventilation of SARS-CoV-2 patients and in surgical intervention. Hence the use of PPE such as plastic face visors, filtering face pieces class 3/2 (FFP3/2) or N95 masks, which filter out 99%/94% and 95% of airborne particles respectively, are imperative in healthcare environments to prevent further spread. Government statistics state that over 761 million items of PPE have been transported to frontline staff across 58,000 different healthcare settings including hospitals, care homes and GPs. To further address demand, the UK government has developed a three-strand plan to enhance national supply and use of PPE. The first strand emphasises clear guidance on differentiating PPE requirements for different healthcare workers in various operational circumstances. The second strand focuses on remodelling logistical provisions and the establishment of a new national supply system, in addition to providing a 24-hour PPE request helpline for healthcare establishments. The final strand addresses the need to meet the increasing future demand of PPE by working with suppliers abroad and local industries, including Burberry and Rolls-Royce, to push domestic production[2,3]. UK PPE guidelines have been developing consistently throughout this pandemic as new evidence emerges. Current PPE includes respirators, fluid resistant surgical masks, full-face shields, visors, disposable gowns, gloves, aprons and polycarbonate safety spectacles or equivalent. A full-face shield or visor is recommended during AGPs, especially those performed during operating procedures. FFP3 grade PPE is recommended for all staff, while FFP2 and N95 can be used if unavailable due to shortages. To ensure adequate protection for all individuals, appropriate fit testing must be conducted by trained individuals, as determined by the British Safety Industry Federation (BSIF) scheme who work closely with the Health and Safety Executive (HSE). Additionally, hospital staff must be trained in donning and doffing PPE, ensuring an adequate seal has been achieved. Discarding disposable PPE between patients has been deemed unnecessary due to evidence illustrating no reduction in risk of transmission. This drove updates to guidance ensuring PPE is used sparingly and on a case by case basis. Furthermore, recommendations encompassing patient use of face masks have been introduced. This compliments regulation advising practitioners on the use of disposable fluid repellent coveralls as an alternative to long sleeved fluid repellent gowns for AGPs. This further increases the requirement for staff training in the correct and safe removal of coveralls[2]. UK PPE guidelines for healthcare staff align well with WHO guidelines, however future circumstances and direction remain unpredictable. WHO and UK guidelines both recommend utilisation of full arm gowns and disposable fluid repellent coveralls for any contact with suspected or confirmed COVID-19 patients, especially during AGPs and other high-risk procedures. Whilst the WHO recommends the use of FFP2 masks, the UK goes further to suggest FFP3 masks for higher risk procedures. In line with WHO guidelines, the UK recommends that single use gloves and disposable repellent coveralls cannot be reused and are to be disposed of after each patient contact[4]. In response to growing concerns regarding the shortage of PPE, innovations in protective equipment are increasingly important. Canelli et al. portrayed the effectiveness of an easily fabricated, clear plastic cube enclosing a patient’s head in preventing the spread of aerosols during AGPs onto practitioners and surroundings[5]. Further work on developing procedures which allow for the re-use of N95 masks via high temperature and UV sanitisation, hence expanding their life span, will be imperative; especially considering updated guidelines released by the UK government advising for the reuse of PPE equipment when shortages present[2]. The SARS-CoV-2 crisis has taken the lives of many and will inevitably continue to affect others. The provision of adequate PPE and clear guidelines on its application will be necessary in preventing the spread of the virus through healthcare workers, minimising further avoidable deaths. Ethical Approval Ethical approval was not required for this letter. Sources of funding No funding received. Author contribution YA was lead author on this letter. MA, NS and ARA contributed equally to the preparation of the manuscript. Trial registry number N/A. Guarantor Yousif Ali. Provenance and peer review Not Commissioned, internally reviewed. Data Statement All data used is publicly accessible. Declaration of Competing Interest No conflicts of interest.

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          World Health Organization declares global emergency: A review of the 2019 novel coronavirus (COVID-19)

          An unprecedented outbreak of pneumonia of unknown aetiology in Wuhan City, Hubei province in China emerged in December 2019. A novel coronavirus was identified as the causative agent and was subsequently termed COVID-19 by the World Health Organization (WHO). Considered a relative of severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS), COVID-19 is caused by a betacoronavirus named SARS-CoV-2 that affects the lower respiratory tract and manifests as pneumonia in humans. Despite rigorous global containment and quarantine efforts, the incidence of COVID-19 continues to rise, with 90,870 laboratory-confirmed cases and over 3,000 deaths worldwide. In response to this global outbreak, we summarise the current state of knowledge surrounding COVID-19.
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            Barrier Enclosure during Endotracheal Intubation

            To the Editor: Clinicians with inadequate access to standard personal protective equipment (PPE) have been compelled to improvise protective barrier enclosures for use during endotracheal intubation. We describe one such barrier that is easily fabricated and may help protect clinicians during this procedure. The barrier studied was an “aerosol box,” 1 which consists of a transparent plastic cube designed to cover a patient’s head and that incorporates two circular ports through which the clinician’s hands are passed to perform the airway procedure. The dimensions of the box are provided in the Supplementary Appendix, available with the full text of this letter at NEJM.org. In our simulation (see video), a laryngoscopist, attired in standard PPE, took position at the head of an airway mannequin. To approximate a forceful cough and generate a spread of droplets and aerosols, a small latex balloon containing 10 ml of fluorescent dye was placed in the hypopharynx of the mannequin. The balloon was inflated with compressed oxygen that was run through tubing inside the mannequin until the balloon burst; the explosion of the balloon represented a crude simulation of a cough. We repeated the experiment without and with the aerosol box, and after each simulation, we illuminated the scene with ultraviolet light to visualize the spreading of the dye. With the use of PPE only, dye was found on the laryngoscopist’s gown, gloves, face mask, eye shield, hair, neck, ears, and shoes (Figure 1). Contamination of the floor occurred within approximately 1 m from the head of the bed and also on a monitor located more than 2 m away. When we repeated the experiment with the aerosol box, the simulated cough resulted in contamination of only the inner surface of the box and the laryngoscopist’s gloves and gowned forearms. Examination of the laryngoscopist and the room with ultraviolet light showed no macroscopic contamination outside the box. Our simulation method, although pragmatic, was not validated for the projectile direction, speed, or turbulence of a true cough, nor did it match the particle-size distribution. Droplets were overproduced as compared with aerosols. Our method of detection could not identify very small quantities of material that could be infectious. Nevertheless, we suggest that our ad hoc barrier enclosure provided a modicum of additional protection and could be considered to be an adjunct to standard PPE. A caveat: we found that the box restricted hand movement and would require training before use in the treatment of patients. Operators should be ready to abandon use of the box should airway management prove difficult.
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              Author and article information

              Contributors
              Journal
              Int J Surg
              Int J Surg
              International Journal of Surgery (London, England)
              Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd.
              1743-9191
              1743-9159
              23 April 2020
              23 April 2020
              Affiliations
              [1]UCL Medical School, University College London, United Kingdom
              Author notes
              []Corresponding author. yousif.ali.17@ 123456ucl.ac.uk
              Article
              S1743-9191(20)30350-2
              10.1016/j.ijsu.2020.04.051
              7177111
              282dc15d-bc5a-4460-b61c-746e837befec
              © 2020 Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd.

              Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.

              History
              : 18 April 2020
              : 20 April 2020
              Categories
              Article

              Surgery
              coronavirus,sars-cov-2,covid-19,personal protective equipment ppe,united kingdom uk,guidelines
              Surgery
              coronavirus, sars-cov-2, covid-19, personal protective equipment ppe, united kingdom uk, guidelines

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