Personal Protective Equipment (PPE) in a Time of Pandemic


In Brief

CoViD-19 is a complex multi-organ disease that kills 3-4% of the patients infected by the SARS-Cov2virus; and the virus is strongly contagious by aerosol droplets, and is, as per most recent data, airborne.  The health risks associated with the virus and the disease has led to significant increase in the use of plastic-derived personal protective equipment (PPE). It is timely and critical to deploy new and improved solutions for PPE disposal.


The Personal Protective Equipment (PPE) Crisis

There are four problems with Personal Protective Equipment (PPE) in this time of Corona Virus disease 2019 (CoViD-19): a) its availability, b) its manufacture, c) its utilization, and d) its disposal.

In the first quarter of 2020, CoViD-19 has spread at remarkable speed across the globe. The virus “responsible for CoViD-19”, as the World Health Organization (WHO) recommends that we describe it, is the second virus of the Corona family to cause severe acute respiratory syndrome (SARS) symptoms – SARS-Cov2.  The earliest case of infection currently known is thought to have occurred on 17 November 2019. Chan and colleagues (1) at the University of Hong Kong first reported incontrovertible evidence of human-to-human transmission of SARS-Cov2 in 7 patients within a 2-family clusters in the medical journal The Lancet in early February 2020. By mid-April 2020, over one million people had been confirmed infected with SARS-Cov2 and were showing active symptoms of CoViD-19, which WHO had declared a pandemic on 11 March. A ‘confirmed’ case, according to WHO, is, as was originally defined for the Middle Eastern Respiratory Syndrome (MERS) in 2014, “…a confirmed case is identified in a person with a positive lab test by molecular diagnostics including either a positive PCR on at least two specific genomic targets or a single positive target with sequencing on a second…”. In the US, confirmed SARS-Cov2 cases are positive outcomes so confirmed by a CDC accredited laboratory or by CDC itself. Over one hundred and sixty thousand patients died globally from the disease within 5 months after the very first case is believed to have emerged in Wuhan, the capital city of the Province of Hubei in mainland China (2).

It is now clear that human-to-human transmission of SARS-Cov2 occurs via aerosol that is expelled from infected patients while they talk, and when they cough or sneeze.  The virus is remarkably stable and can be found to retain its infectivity for many minutes to hours, depending upon whether it remains in air droplets, falls on a rough (i.e. cardboard, street pavement) or flat surface (i.e., glass, aluminum or steel surfaces), in cold or warm surroundings, in humid or dry air. Therefore, and in following well-established science-based public health recommendations grounded in the R0 parameter, that is the basic contagion number of an infectious pathogen first introduced by Prof. Macdonald in his 1952 studies of malaria contagion, and extensively used thereafter, simple principles of public health must be applied to contain the spread of SARS-Cov2 (3).  In brief, R0 is simply rendered as the product between number of contacts, c, per unit time during a given time, t.  That is to say:

R0 = c X t

It follows that R0 that the spread contagion can be slowed down very simply by decreasing c, the number of contacts – for example, by increasing the distance between our human-to-human contacts: that is, physical distancing – and, or by decreasing the length of time we have these human-to-human contacts – for example, by shortening, or minimizing our social interactions:  that is, self-quarantining.  Of course, as social animals, the very fact of being socially distant from our loved ones is very taxing and very stressful. Neither psycho-emotional conditions help our immune system combat infection.  Therefore, one must be careful to be physically distant, while remaining psycho-socially connected with friends and family.

In brief, all that protects individuals from SARS-Cov2-infected co-workers, friends and family is physical distance.  And all that we can do, individually, to protect those we love if we believe, or know that we are SARS-Cov2-positive is wear face-mask, physical distance from each other (6 feet at least), and self-quarantine.  Breaking these two cardinal rules of public health too early in a pandemic will be catastrophic, as evinced by our accumulated scientific knowledge about R0 over the past six decades.

The remarkably aggressive morbidity and mortality of the pandemic has taken the world by surprise, and even the countries that boasted to be better prepared for an unexpected epidemic or a pandemic find themselves hardly able to cope with the rapid exponential growth in SARS-Cov2-positive cases, closely followed by an equally rapid exponential growth in CoViD-19 hospital admissions, inexorably followed some days later by similarly sharp exponential growth in intensive care unit (ICU) admissions most often requiring assisted respiration. Ninety percent, and in certain cases even a higher percentage of ICU patients on respirators or C-PAP expire within a few days. Hospitals are overwhelmed, ICU beds in very short supply, and respirators often lacking:  hospital staff is overworked, stress, anxious and suffering from extraordinary occupational stress, which exposes to increased danger of errors in safety protocol that can be fatal.  Reports are sadly fast growing on the number of nurses and doctors, who attend to CoVid-19 patients, getting infected with SARS-Cov2, requiring hospitalization, and dying among the very patients that they were caring for just days prior.

All that separates the active hospital staff and CoViD-19, all that protects them for the SARS-Cov2 virus that infects their patients is their PPE. Indeed, all that separates each one of us from an unsuspected exposure to the virus while we take our dog for a morning walk, pick up the mail, or buy groceries, even as we dutifully respect the cardinal rule of physical distancing, is PPE.

We are called to use face masks and gloves as a minimal protection against casual SARS-Cov2 exposure. But hospital staff is called to wear masks and face shields, double gloves, protective coat and aprons; and even so, as noted, the number of CoViD-19 cases among EMS personnel, nurses and doctors who daily care for these patients for interminable shifts is rising alarmingly.

The PPE crisis is real.  It is real in the US and globally: no country across the world was prepared to a pandemic of such virulence. Every hospital in every continent had a reserve supply of PPE for its staff, but none had expected that PPE would be used at such a rate.  PPE manufacture soon reached its limit, and severe backlog of orders were reported worldwide.  The problem of PPE availability at present is real, as that of its manufacture for the months ahead of the current first wave of this pandemic, and its expected second, third and perhaps fourth wave into 2021, and, although unthinkable, 2022 or even 2023.

 

PPE Utilization and Disposal Crisis

The present writing, however, focuses on the problem of PPE utilization and disposal, which is just as real, and is arguably a greater threat to the ecological balance of our planet. PPE availability to health care providers today, and PPE manufacture for them to use in the weeks, month and years ahead are issues of storage and industrial production that will find solutions in timely ramping up of industrial productivity for these and critical items.

PPE utilization and disposal are issues of use, refuse and recycling, which require an important re-thinking of the modes presently at our disposal. The crisis of PPE utilization arises from the fact that hospital personnel are required to use so much more PPE than before the pandemic.  The daily rounds by the doctor and the fellows and residents on hospital floors and the ICU’s rarely required the medical and the nursing staff to use PPE, unless the patient was known to be infectious or immunosuppressed.  Today, in a pandemic, hospital nurses and doctors must wear PPE at all times, often to the point of developing skin abrasions. The extended utilization of PPE in the hospital setting has led to a crisis of management of used PPE.  Hospitals were not set up to have to manage, triage, reuse and store until removal of such an extensive volume of used PPE. That problem too, however, is an issue of hospital space and human resources, for which hospital management administration can and must find prompt solutions.  But, this crisis not strictly the focus of this writing.

This writing focuses on possible solutions to the problem of disposal of used PPE in the CoViD-19 pandemic caused by the highly infectious and resistant SARS-Cov2, which is suspected to stick to clothing and plastic surfaces, and remain stable and virulent for hours, if not days. For all intents and purposes, PPE used by the hospital staff, and PPE used by each one of us individually for that matter, must be regarded to be biohazardous.  The sheer volume and rapidity at which we accumulate used biohazardous PPE during this pandemic is a timely and critical problem that must be addressed presently, lest we find ourselves short of viable solutions as this mounts into a gargantuan problem of pollution of plastics and plastic-derived health-threatening products.

 

Biohazardous PPE Disposal – Previous Experience

The constituents of PPE vary, but all consist of some plastic derivative, with various degrees of threat to the environment.

  • Gloves: Latex-rubber gloves provide superior tactile sensitivity along with comfort and fit, but may produce skin lesions of various severity. Polyisoprene gloves provide the performance of latex gloves without the risk of natural rubber latex sensitivity. Neoprene is a cost-effective latex-free surgical glove alternative to polyisoprene.
  • Gowns and Aprons: Surgical gowns and aprons are essential made of nonwoven polypropylene fibers. The nonwoven fabrics for surgical gowns and drapes are most often spunlace, which is a hydro-entangled material derived from wood pulp and polyester fiber. Aprons are usually light-weight polyethylene; and one-time disposable aprons are most often of latex-free polypropylene material.
  • Scrub caps: Surgical bonnets/scrub caps are usually made of cotton or sweat absorbent cloth. While comfortable, they are more effective in protecting the medical staff’s head from infected aerosols when integrating latex or polyester materials, or a polyethylene coating to minimize aerosol penetration.
  • Shoe covers: Non-skid shoe covers usually have a polyethylene coating to reduce fluid penetration.

In general terms, rubber latex and its derivatives, including polyisoprene, the polymer derivative of natural rubber (isoprene), a colorless volatile liquid that can have important consequences to the atmosphere and the ozone layer, and neoprene, the polymer derivate of chloroprene, are safe. However, both products can induce dermatitis reactions of various degree of severity to susceptible people. Rubber Latex can be degraded, but bacterial-aided biodegradation is slow; by contrast isoprene is itself a colorless volatile liquid that may have important consequences to the atmosphere and the ozone layer. Chloroprene is a flammable colorless volatile liquid (code 3) with serious potential occupational health and safety risk, although neoprene is more stable and more innocuous. Polyethylene is the most common type of plastic, but is also the least degradable plastic, and, because it accumulates in landfills, is a serious threat to a sustainable environment. Polypropylene, the second-most widely produced plastic after polyethylene, is recyclable and has the number “5” as its resin identification code by the American Society for Testing and Materials. Lastly, polyester, a polyethylene terephthalate derivative, is responsible for large amounts of micro-plastic pollution found on our lands and in waters.

The medical establishment has been familiar with PPE ever since the beginning of the HIV/AIDS era. Policies were strengthened following the Ebola, the SARS and the MERS epidemics. In brief, double glove recommendations, face masks and face shields, surgical gowns, aprons, bonnets and shoe covers became ubiquitous, if not mandatory. PPE should be put on in a certain order and set by a partner to ensure complete seal; and PPE should be removed in a pre-set order with the aid of a partner to ensure no cross-contamination.  All used PPE must be tossed in a biohazard disposal bag, processed in the autoclave for sterilization at 250⁰F (121⁰C) for 60-90 minutes to ensure neutralization of all biohazardous particles, including human viruses. Only then can used autoclaved PPE be processed as regular hospital trash, sent to the landfills, and processed as recycling plastics.

 

Processing CoViD-19 PPE

The sheer magnitude of the current pandemic, the expectation that it will continue to expand for the foreseeable future, and the shear amounts of PPE used per day in every city and rural hospital in every country of the world, reveals an important problem that is emerging globally:  how to develop effective measures to process spent CoViD-19 PPE after use.  These materials must be sterilized as soon as possible, lest the contaminating SARS-Cov2 virus spread through PPE.  But hospitals do not have the space, nor the funds to build autoclaves large enough to process the sheer mass of biocontaminated plastic materials. All spare funding is used, at present, to purchase more PPE, more testing kits, more ventilators, and to hire more staff; and all available space is transformed into ward area for additional beds, if not ICU units.

Even if concerted safety protocols were designed for prompt and secure evacuation from the hospital grounds of all biohazardous PPE for sterilization and processing, new sites endowed with many sites holding multiple large autoclaves capable of processing multiple enormous loads round-the-clock need to be built with local (City, County and State) and Federal funds most urgently.  We cannot afford to procrastinate on this problem:  the crisis is already upon us: biohazardous PPE must be decontaminated now before it fosters further expansion of the pandemic.

But even if all the biohazardous PPE were to be decontaminated tomorrow, that still would be only half the solution to the significant crisis now facing the planet:  an enormous spike in the amount of plastic waste generated per diem, which will have catastrophic effects on our atmosphere in the form of gaseous pollutants, on our lands and seas in the form of non-biodegradable plastics, and our health and that of our oceans in the form of microplastics.

We have not been able to contain plastic pollution of our planet before Covid. It is possible and even probable that plastic pollution after Covid will be even more terribly ravaging then before. We must act now: carefully plan, and as part of ‘re-opening the country’ and the world, returning to work and striving again for economic stability on our plant, integrate new and improved protocols for plastic recycling, for plastic containment and for PPE decontamination.  Solutions must be local and grassroots, while supported by concerted bi-partisans State, Federal and world-consortia politics and economics. The survival and humanity and of our planet depends on it.  Let it not be said that we, earthlings, defeated Covid, only to be defeated by the very pollution aftermath we created in the process.

Acknowledgement: The author thanks Climate Reality Project, the Climate Reality Leadership Corps, and other organizations also involved in the laudable fight to restore our planet from the climate crisis, such as for example 5Gyres.  The author also recognizes the EMS personnel, firefighters, first responders, registered nurses, nurse’s aides, hospital volunteers, dentists and medical doctors, and all those who care for patients afflicted by CoViD-19 in the pandemic we are now traversing, the soldiers and heroes on the frontlines of this “global war against an invisible enemy”.

Francesco Chiappelli, Ph.D., Dr. Endo. (h.c.), Professor Emeritus, UCLA Center for the Health Sciences, CSUN, Department of the Health Sciences, Climate Reality Project Leadership Corps, 5Gyres Ambassador, Global Catholic Climate Movement, International Research Consulting  chiappelli.research@gmail.com, francescochiappelli.com

 


References

  1. Chan JF, Yuan S, Kok KH, To KK, Chu H, Yang J, Xing F, Liu J, Yip CC, Poon RW, Tsoi HW, Lo SK, Chan KH, Poon VK, Chan WM, Ip JD, Cai JP, Cheng VC, Chen H, Hui CK, Yuen KY. A familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: a study of a family cluster. Lancet. 2020 Feb 395:514-23. PMID:31986261
  2. Chiappelli F. Putative Natural History of CoViD-19. Bioinformation 2020 2020 16: 398-403.
  3. Chiappelli F. CoViD-19, a word with Francesco Chiappelli. L’Italo-Americano, 16 April 2020, 30 April 2020, 14 May 2020, 28 May 2020, 11 June 2020, 25 June 2020 14 ff.