Whenever any pandemic accelerates, per se the coronavirus disease 2019 (COVID-19),
it is commonly observed that health care systems face tremendous workload in terms
of infectious patients seeking testing and care. During such public health emergencies,
personal protective equipment (PPE) like-gloves, surgical face masks, air-purifying
respirators, ventilators, goggles, face shields, N95 respirators, and gowns are essential
in preventing the spread of infection among the patients and health care workers (HCWs).
As in this critical phase, a shortage of all of these PPE is about to develop or has
already developed in high demand areas like triage, isolation wards etc. Previously,
PPE was commonly used in the hospital environment, is now a scarce and precious commodity
in many locations when it is needed most to care for highly infectious patients [1].
It is even more difficult to get PPE when common people get started to use/stock PPE
in fear of infectious disease contamination without following national guidelines,
which is an added insult to the injury of health system. During a pandemic, whether
it is striking in developing or developed countries, an increase in the supply of
PPE in response to this new demand will require a large increase in the production
and distribution of those equipment. However, most of the time it is not possible
to manufacture bulk PPE as it requires time, infrastructure, and other resources.
In a pandemic situation, a hospital is unlikely to share their PPE and other protective
resources to other hospitals or medical institutions as they may require it too for
ensuring their own safety [1]. Moreover, rapid coordination of such resources in the
state or national level can be useful so that equipment are not being used can be
mobilized with other institutions experiencing scarcity. Such approaches may foster
collaborative efforts against COVID-19 ensuring efficient use of resources at the
systems level. Nonetheless, it is only possible to address COVID-19 if we can flatten
the epidemic curve by classical intervention measures like lockdown and social distancing
processes, which may give lead time to many health care systems to arrange further
management of the outbreak. But during exponential phase of pandemic as rapid increase
in COVID-19 patients it is very challenging to provide adequate PPEs to the health
workers of any country. To solve this problem, i.e., to optimize the use of face masks
during the pandemic, the Centers for Disease Control and Prevention (CDC) identifies
3 levels of operational status: conventional, contingency, and crisis [1]. During
normal times, face masks are used in conventional ways to protect HCWs from splashes
and sprays. When health care systems become stressed and enter the contingency mode,
CDC recommends conserving resources by selectively cancelling nonemergency procedures,
cancelling outpatient encounters which might require face masks/PPEs.
When face masks are unavailable, the CDC recommends use of face shields without masks,
taking clinicians at high risk for COVID-19 complications out of clinical service,
staffing services with convalescent HCWs presumably immune to SARS-CoV-2 (severe acute
respiratory syndrome coronavirus 2), and use of homemade/handmade masks, perhaps from
bandanas or scarves if necessary [2]. Many communities in the India and globally are
rapidly entering PPE crisis mode. Recently news are circulating about the unconventional
solutions for PPE at local hospitals, such as plastic garbage bags for gowns and plastic
water bottle cut outs for eye protection [3]. Shortage of sanitizer can be solved
by using handmade sanitizer having 90% concentration of alcohol, this type of ideas/news/decisions
are facing many continued criticism from medical fraternity as they are perceiving
as mockery/knee jerk response. Plans for resupply through the repurposing of existing
industrial capacity are welcome but seem unlikely to solve the shortage quickly enough
as supply chains become affected in the pandemic [4].
The task force to combat COVID-19 was created to solve precisely this problem, but
its inventory is not transparent and news reports suggest its supplies are being distributed
unevenly or are insufficient to meet demand [5]. HCWs need supplies and solutions
for these shortages now, and for that reason, the Journal of American Medical Association
(JAMA) issued a call for ideas for how to address the impending PPE shortage [6].
There were many proposals (Table 1).
Table 1.
Methods of PPE conservation and management.
Import-Purchase PPE
Use of smart technology-drones, telemedicine, etc
Reuse-by sterilization
Employ healthy workers
Reduce non-essential services
Use government solutions
Reduce patient contact
Use innovative solutions
Alter staffing
Stratify use by risk profiling
Rely on local solutions
Manage supply
One endeavour is Project N95, where demands are identified and N95 masked to be supplied
on that area only [6]. Sterilization of used PPE with agents ranging from ethylene
oxide, UV or gamma irradiation, ozone, and alcohol was identified as common proposal.
There were also novel proposals such as mask-fiber impregnation with copper or sodium
chloride, these ideas are not unscientific they were field tested after prior viral
epidemics to determine the feasibility of sterilizing PPE [7]. Although scientists
acknowledged that the uncertainty about the effects of these sterilizing agents on
the structural integrity of PPE, and there is some evidence the fibers in masks and
respirators that filter viral particles can degrade and lose their efficacy with PPE
reprocessing [7].
Some of the other idea was to reduce patient contact so most of the private clinics
remains closed and most of the clinicians doing teleconsultations. Alter staffing
is also considered as important step, health department of India gave directives to
the medical colleges that the all health care workers will work on a rotation basis
for minimizing the contact risk [8].
Home delivery of online groceries are another option. In India, a company named “Big-Bazaar”
is already providing online groceries to the peoples who are confined in their homes
due to lockdown [9]. However, such technology-based services are contingent on the
availability and accessibility of those services in different countries. In India
and other low and middle-income countries, innovative technological interventions
should be devised and deployed to ensure timely and efficient distribution of goods
and services. Such socioeconomic approaches may not only reduce the risks of COVID-19
transmission but also ensure daily necessities of the citizens are met adequately.
Other measures are like appointing the healthy staffs to the service area and the
staffs who have medical conditions are exempted from service delivery.
Other than that, using government services like relaxing importing rules, use of police
forces, converting railway coaches as isolations are also important and innovative
steps.
Legislative steps like mandatory social distancing, curfew, can help the crisis period
by flattening the epidemic curve [10].
These are the short-term conventional solutions. Here we propose few more which is
out of the box thinking like-production of sanitizer at mass scale by the alcohol
industry during COVID-19 crisis period, in India is happening right now [11]. Similarly,
in India, the textile industry and hardware industry is producing bulk masks, gowns,
caps, protective shields etc instead of producing clothes [12]. Moreover, the automobile
industry can make ventilators instead of producing vehicles at this critical period.
In India, the Mahindra group came out with a prototype ventilator and soon they will
start producing [13].
Besides this, global evidence on managing the shortage of PPE can be useful to inform
future strategies. For example, Taiwan experienced a critical shortage at the beginning
of the COVID-19 crisis. Implemented this issue was mitigated by several strategies
including rapid production and distribution of PPE to prioritized centres resulting
in a declined shortage of PPE. These strategies used a 3-tier personal protective
equipment (PPE) stockpiling framework that could maintain a minimum stockpile for
the surge demand of PPE in the early stage of a pandemic [14]. Some of these strategies
include export prohibition, rationing, and increase production through either mandates
or voluntary productions [15]. We believe many lessons can be learnt from countries
like these. These countries provide real-time examples that can be copied by others
with similar healthcare systems.
Such local and global innovations should be evaluated and adopted ensuring patient
compliance during COVID-19 to improve health outcomes.
In our opinion smart questions need smart answers, in the era of emerging and re-emerging
disease outbreaks like COVID-19, besides the conventional approach we must think differently
and implement the success stories of similar countries in India. While health systems
in most of the countries are struggling to fight COVID-19, the operational challenges
including safety of the health workforce and prevention of transmission is much higher
in resource-constrained contexts. It is essential to prioritize these health issues
and adopt best practices to ensure the availability, accessibility, and utility of
PPE and other resources in an efficient way. Multilevel policy interventions with
user-level quality assurance may help in mitigating those issues. Perhaps, more importantly,
we have to extend our support to each other, act together for our survival, without
blaming each other.