Personal protective equipment used by obstetricians and obstetric nurses during the COVID-19 pandemic in Mansoura, Egypt

Introduction

COVID-19 is a global pandemic affecting all populations, and subsequent worldwide aggressive measures have been taken to mitigate the spread of the infection (World Health Organization (WHO), 2020). According to a study on COVID-19 characteristics and predicting factors among healthcare providers in a developing country, approximately two-thirds of exposure occurred primarily during healthcare provision. Furthermore, one-fifth of the cases were confirmed COVID-19 cases; the majority of them had mild to moderate symptoms, with only 9.1 percent asymptomatic. Almost all became infected while on duty (97.4 percent). Infected patients (39%) were the most common source of infection, followed by colleagues (22.1%), household contacts (5.2%), and unknown sources (33.8 percent) (El-Sokkary et al., 2021).

Obstetricians have worked tirelessly for the past three decades to enhance women’s outcomes through the use of evidence-based medicine. The present COVID-19 epidemic has flooded this standardized method with a deluge of contradicting material, causing uncertainty in the birthing ward about recommended practices. As the infection spreads throughout the population, obstetricians are becoming more concerned (Sichitiu & Desseauve, 2020).

Asymptomatic patients are contagious and thus are at a high risk of nosocomial infection (Rothe et al., 2020). Therefore, strict PPE usage for doctors and midwives is necessary at labor if universal screening is not performed (Umazume et al., 2020).

Regulating and adapting all aspects of infection prevention can be difficult in the unfortunate event of a maternal collapse. The delivery room is overloaded when many personnel simultaneously attempt to resuscitate the collapsed patient, perform a perimortem cesarean delivery, and resuscitate the newborn. The resuscitation team should don full PPE. The most common frequent & serious cross-infection to healthcare workers during outbreaks happened when first responders were not wearing the recommended PPE (Schwartz and Graham, 2020).

Wearing N95 respirators can reduce clinical respiratory infections by 73 per 1,000 healthcare workers (HCWs). In laboratory-confirmed bacterial colonization, N95 respirators had a protective effect. N95 respirators were found to be more effective in preventing laboratory-confirmed respiratory viral infections and influenza-like illnesses. As regards protection of HCWs, no direct high-quality evidence was found on whether N95 respirators are better than surgical masks for from SARS-CoV-2 (Iannone et al., 2020).

Despite the protective PPE value, one study reported that physicians who work in the intensive care unit (ICU) and deal with such patients are naturally anxious. They would be unable to drink, eat, or go to the toilet for approximately 6 hours after wearing full PPE as required in the ICU. Taking off PPE after duty hours necessitates training and extreme caution to avoid self-infection (Alsubaie et al., 2019).

Worldwide, reports of PPE scarcity and unavailability are emerging. HCWs and the general press use social media to report on the reusing of PPE or the use of household and self-made items in place of PPE. There is limited evidence on the effectiveness of these practices, but they have occasionally been implemented on the advice of their employers or health organizations (England, 2020; CDC, 2020). It is believed that no previous studies discuss the pattern of PPE utilization among obstetricians and obstetric nurses during the COVID-19 pandemic in our country.

Methods

Results

Adverse health effects of full PPE use

The most common health effect of full PPE use is a sense of health (79.5%) followed by a sense of thirst and pressure areas (64.7% and 64.3%, respectively; Figure 1). More than two-thirds of affected HCWs (68.3%) had more than two symptoms. Adverse events were not associated with age, gender, job description, duration of work in years, work hours, or work in hospital isolations (p > 0.05; data are not tabulated).

Figure 1. Adverse effects of full PPE use among study participants.

Discussion

This is the first study on PPE use among healthcare workers in the obstetrics and gynecology departments during the COVID-19 pandemic in Egypt. PPE use is influenced by the workload of HCWs as a matter of hours and patients, baseline resources in these hospitals, and stockpiling of personal equipment and safety training for those HCWs (Tabah et al., 2020).

The present study showed that full PPE use was 37.7% and 34.9% during CS and emergency deliveries, respectively. Full PPE use during CS was significantly associated with longer work hours (≥8 h) and formal training on PPE use. A different description for the pattern of full PPE per facility was noticed by a nationwide survey in Japan including core facilities and affiliated hospitals of obstetrics and gynecology training programs. Authors reported that full PPE was used by doctors and midwives in 7.1% and 6.8% of facilities, respectively, taking into consideration the different definitions of full PPE use in both studies.

The present study showed that most healthcare workers used sterile gloves, sterile fluid-resistant gowns, and surgical masks during CS and emergency labor. Fewer HCWs used face shields and goggles. Only one-tenth used N95 due to the absence of baseline resources of these hospitals. Of the HCWs, less than one-third reported washing gloves (26.8%) and reusing gowns (14.8%). Surgical masks and N95 respirators are the most consistent and complete support measures used by healthcare personnel, according to a Cochrane-approved systematic review on physical interventions to reduce respiratory virus transmission undertaken in 2011. N95 respirators are non-inferior, according to the highest quality cluster-randomized controlled studies included in this systematic review (Jefferson et al., 2011).

Another web-based survey conducted by Tabah et al. (2020) and distributed worldwide in April 2020 among ICU HCWs found that more than half of the respondents (52%) reported that at least one piece of the standard PPE is not available, and 30% reported that at least a piece of single-use PPE was being reused or washed as a result of shortages. Most of the available PPEs were designed for single-use and brief duration. Hence, the authors reported that urgent design and manufacture of PPE that can be safely worn and remains effective for extended durations are needed.

Similarly, the first nationwide Japanese survey reported that N95 masks and goggles or face shields were out of stock in 6.5% and 2.7% of facilities, respectively. In addition, disposable N95 masks and goggles or face shields were reused after resterilization in 12% and 14% of facilities, respectively (Umazume et al., 2020).

Masks and respirators play a role in the protection of health workers according to high level of agreement among key agencies. However, there are current differences between these agencies in terms how and when the different products are used. Different recommendations have been made by the World Health Organization (WHO), the US Centers for Disease Control and Prevention (CDC), and other leading health organizations. For example, the WHO recommends using N95, FFP2, FFP3 standards or equivalent in care settings for COVID-19 patients where aerosol-generating procedures are used and medical masks are used in the absence of aerosol-generating procedures (WHO, 2020). In contrast, the US Centers for Disease Control and Prevention (Center for Disease Control and Prevention, 2020) recommend using respirators during both routine care of COVID-19 patients and high-risk situations.

In this study, more than two-thirds of the subjects followed the correct sequence of donning and removing PPE and receiving formal training on PPE use (67.1%, 66.4%, and 63.5%, respectively). These results came lower than those observed among ICU workers in a worldwide web-based survey who found that most of the respondents (83%) had formal training in PPE use. This included training at the start of the institution (13%) and within the last two months (60%) due to the COVID-19 pandemic (Tabah et al., 2020).

In addition, current study results revealed that receiving formal training on PPE use among obstetric physicians and nurses was a significant predictor of full PPE use together during CS and emergency labor. These results are in agreement with an Italian study on a cross-section of physicians which reported that access to adequate information on the use of PPE was associated with a better ability to perform donning and doffing procedures as an example for proper PPE use (Savoia et al., 2020).

The most common health effects of full PPE use in the current study is a sense of heat (79.5%) followed by a sense of thirst and pressure areas (64.7 and 64.3%, respectively). More than two-thirds of affected HCWs (68.3%) had more than two symptoms. These results were different from the results found in ICU workers during the pandemic where 80% had adverse events including heat (51%), thirst (47%), pressure areas (44%), headaches (28%), inability to use the bathroom (27%), and extreme exhaustion (,20%). They were all associated with longer duration of shifts wearing PPE. However, in the current study, adverse events were not associated with age, gender, job description, duration of work in years, work hours, or work in hospital isolation (Tabah et al., 2020).

Conclusions

Most obstetricians and obstetric nurses used surgical masks, gloves, gowns, foot protection, and, to a lesser extent, N95, goggles, and face shields. Work hours (>8 h) and formal training were significant predictors for full PPE use.

Based on the findings of the current study, adding N95 or FFP mask and eye protection for safety programs in obstetrics and gynecology departments during aerosol-generating procedures is recommended. Also, reducing long shift work hours that may lead to adverse events due to full PPE use is recommended. Providing simple training videos about different types, proper PPE donning and removal, disinfection of reused equipment, and hand hygiene frequently as part of CME hours of physicians and nurses are required to cope with this emerging threat.

Data availability