On the Personal Protection Equipment (PPEs) for Healthcare Workers in the Light of Increasing Numbers of COVID-19 Patients
Joint Statement by Jan Swasthya Abhiyan and All India Peoples Science Network
The JSA and AIPSN draw the attention of the public and the media to the major crisis that has developed in health worker safety due to the lack of PPEs. Not only will the healthcare staff be at higher risk of getting the infection, widespread infection in healthstaff would sharply decrease the capacity of the country to delivery health care services in both the public and private sector.
The greatly increased need for PPE:
COVID-19 cases are growing in India with every passing day. It falls on the frontline healthcare workers to treat and care for them. However, the lack of proper protection in the form of Personal Protective Equipment (PPE) is preventing health workers to make effective interventions in the containment of COVID-19. It is putting lakhs of health workers including sanitation and other frontline personnel tasked to treat patients and clean premises of health facilities and other public spaces at the risk of contracting the virus.
Healthcare workers across the spectrum have been hit by the lack of masks, gloves and gowns. Four thousand Community Health Volunteers (CHVs) in Mumbai have been directed to search for suspected COVID-19 affected patients without being given enough protective gear and sanitisers. We have learnt about instances in private hospitals where the nurses are working in Intensive Care Units (ICUs) without masks and where the private hospital is treating Severe Acute Respiratory Illness Patients who have not been tested for COVID-19.
We are also privy to many reports that any doctor or nurse managing any general out-patient unit anywhere in the nation is now at increased risk of getting exposed to COVID 19 patients and developing the disease- since mild and moderate cases are not identified and isolated in India’s approach to managing the epidemic. Indeed the past week has seen an alarming increase in healthcare providers who are so effected
The doctors across India have been demanding PPE to go ahead with their work uninterrupted. The fact of their higher risk for infection, instead of bringing support has often exposed them to violence and hostility as sources of infection into the community. On 21st March, Doctors Association Kashmir sent a letter to the advisor to lieutenant governor of the UT of Jammu and Kashmir citing acute shortages of personnel protection gear especially N95 Masks, PVC coated gowns and goggles. There are similar reports from all states.
As the spread of COVID-19 increases, providing PPE at all levels of care – community as well as hospitals , to those seeing COVID patients and those managing general patients– is of paramount importance. And to rationalize the use, those at higher risk like those collecting samples or those in the frontline of care provision have far more extensive and stringent requirements of PPE as compared to others.
Unpreparedness of Indian Hospitals for Infection Control:
The Indian healthcare system has long neglected infection control in its health facilities. Studies show that not more than 20-30% of hospitals have Infection Control and Prevention (IPC) guidelines in place. Fewer follow them diligently. After SARS epidemic and then due to the increased focus on antibiotic resistance and drug-resistant tuberculosis, IPC started to gain currency in policymaking circles with ICMR and NCDC revising their guidelines for hospital acquired infections.
Despite the guidelines, hospitals have never invested in procuring PPE for their staff, letting them suffer on the way. COVID-19 has brought this historical neglect to the fore. Had the Indian health system been investing in protective gear for its staff from before, we would not be facing the crisis to the extent that we do today.
Delays, and inadequacy of government efforts on procure PPE :
The role of the government over the past two months is also baffling.. The first case of COVOD-19 was registered on 30th January in India. Taking cognisance of the seriousness of the issue, the government issued an order prohibiting export of all PPE. But it was amended on 8th February allowing export of surgical masks and all gloves except NBR gloves. The restrictions were further relaxed to include more items on 25th February.
TheWHO issued an interim guidance regarding PPE on 27th February noting that there is going to be a global shortage of PPE and hence came up with a document on its rational use. Taking cue from this, the government should have moved fast to prohibit export of domestically produced PPE and raw material so as to ensure its availability in the country. But that order came only on 19th March.
Current government efforts at procurement are far too little, and very late, making it unlikely that we would have adequate PPE anytime soon. The government has placed the order of 7.5 lakhs body overalls to be supplied by May. However, the need could be upto 5 lakhs of body overalls a day. Similarly the order of 60 lakh N95 masks and one crore three ply masks will be grossly inadequate in the current scenario.
Barriers to scaling up production:
We also understand that there are many constraints to scaling up of production to desired levels. A few of the PPE components are not manufactured in India and there is an import dependency. Also, there is shortage of the required raw material in the country making increased manufacturing a problem. Further there is is disruption of supply chains, making the availability of these equipment from import markets difficult. Now when the orders are placed, many manufacturers find that due to the lock down immediate procurement of raw material or hiring and deployment of labour are both very difficult.
Part of the barriers are in the past and relate to our economic liberalisation program, which has eroded the manufacturing base of even low technology content products and created import dependency. Though our potential capacity in required technology, in our hour of need, we find that our past policies have compromised our self reliance in this secor, and therefore oour health security. Considering the huge demand from many countries for PPE India cannot depend on the import to meet its demands. Therefore the government has to scale up the production and maintain this in the future also
Recent Welcome Moves to address the crisis:
We welcome the letter of NPPA to all states to find out the inventories and available production capacity. During the initial days there was no mechanism to find out the inventory and manufacturing capacities existing in the country.
We also appreciate the government’s effort to place PPE components like mask and hygiene product like hand sanitisers and the raw materials for their production as essential commodity and imposing price control over them. However, it is important to ensure uninterrupted supply. While the export restrictions are an important step to ensure the domestic supply, it is also important to enhance the production capacity to also supply to many countries who are in need of these products. However, such export should be at the government-to-government level to avoid profiteering at the cost of public health and also to ensure domestic supply.
To fulfil its needs the government has placed a number of orders and is is now supervising the manufactures,
More steps required to achieve required production capacity.
However the number and output would be very low compared to the demand.. To close this gap, government should instruct select large scale manufacturing companies to start production of the important elements of PPEs. Further, though specificiations are provided, government would also need to transfer designs and other blue prints to new actors to initiate manufacturing. Further, government should directly procure these specified raw materials and supply to the end-product manufactures who are supplying the government. These steps would be urgently required to enhance the efficiency in the supply and production of PPE.
Another important issue we noticed is that the Indian PPE requirement specifications as well as guidelines for use are higher than the WHO prescribed standards. We are afraid that such higher standards would create scarcity of prescribed PPE and result in the failure of the real purpose. Another important issue is the guidelines to be framed for the reuse of Hazmat Suits after autoclaving. At the moment the supply is limited to disposable PPE kits which are in limited supply. The government should set up an expert committee to arrive at these specifications and guidelines which are more conducive to the Indian context and to meet our immediate needs. The expert committee should be tasked with constantly revising the decisions as new and better data arrive. We have done some preliminary exercise in this regard that we can share on request.
To increase production of PPE and ensure safety of healthcare workers, we make the following demands from the government:
- Urgently ensure availability and free supply of PPE to all health workers. directly or indirectly providing care for COVID 19 patients at per their level of risk. Towards this end government should revisit its specification and guidelines for use.
- Private hospitals should be directed to follow the guidelines and not put their staff at risk.
- Include all health workers seeing general outpatients as also at higher risk due to unidentified mild and moderate and even asymptomatic cases in circulation and develop recommendations on PPE for them.
- Scale-up the production of PPEs within the country. Government should identify the products that are not currently manufactured in India and within a short deadline seek proposals and technically and financially support the manufacturing of those components in a decentralised manner so all states have at least one manufacturing unit.
- In order to enhance the number of manufactures, government should publish the designs and blue prints along with the specifications and convert largescale apparel production firms to start the immediate production of PPE components.
- In order to expedite the procurement and supply of PPE equipment, government should involve more public sector establishments. Currently, the government has given HLL Lifecare Limited, a government-owned company, rights for procurement of PPE. Approval for more public sector institutions in the procurement would speed up the procurement and supply.
- Issue guideline for the appropriate disposal of PPEs used by health workers as well as face masks that public use
- Ensure transparency with regard to the procurement prices and suppliers and the number of procurement.
- Set up an Expert Committee to establish PPE requirement specifications as well as guideline for use in the Indian context. Its role should include constant revision in light of new and emerging data.