Critical to protect our doctors and nurses during COVID-19

South Africa’s extended Coronavirus (COVID-19) lockdown is merely slowing down the infection rate to allow for the urgent continued expansion of its currently inadequate treatment and life-saving capacity. It’s a reality many people validly complaining of income and several other lock-down sacrifices have yet to understand.

Nation-wide, field hospitals are being erected, buildings re-purposed, and hospital patient-decanting plans honed while globally scarce personal protection equipment is creatively procured. Some hospitals are even converting spare basement parking space into standby mortuaries – and ordering in extra stocks of body bags. Experts preparing for the inevitable surge of infections once the economy-damaging lockdown is relaxed or lifted, have issued an earnest warning; we must adequately protect our thinly spread, courageous doctors and nurses from infection, or risk having far too few medics to care for us. That would prompt an unimaginable crisis.

Recent in-hospital COVID-19 outbreaks highlight a disproportionate number of healthcare staff rendered ineffective by infection, including a handful of healthcare worker deaths. South Africa’s COVID-19 Command is scrambling to secure stocks of personal protective equipment, (PPE’s), for them in the midst of what is a global procurement war. Frightened nursing unions and doctor bodies have begun exerting their right to self-protection and seeking clarity on their legal rights in what will soon be an unprecedented ‘all hands-on deck,’ highly abnormal practice environment.

According to Dr Hlombe Makuluma, medico-legal advisor at EthiQal, a leading South African provider of professional indemnity cover for healthcare specialists, employers are obliged to provide a safe working environment (as far as reasonably possible), and healthcare workers have the right to remove themselves when they reasonably believe their lives or health to be in imminent danger.

Says Dr Makuluma; “Many doctors are worried about their personal safety-and whether their hospitals will be able to provide adequate PPE.

These concerns are in addition to the many other medico-legal questions arising as a result of the pandemic.  For example, it’s almost certain many doctors will be asked to work outside their normal scope of practice to counter the coronavirus, given the overall paucity of healthcare workers. 

“Our offices are inundated with doctors seeking re-assurance on indemnity cover in this challenging new medico-legal environment,” says Dr Makuluma.

To protect staff and patients, current priorities in hospitals and clinics include clear infection and prevention control policies, adequate training for healthcare and auxiliary staff, efficient air filters and ventilation rates in confined spaces and physical barriers where appropriate. Sufficient resources to enable personal hygiene, such as no-touch refuse bins, hand soaps, alcohol-based sanitizers and disposable towels are also vital. This goes hand-in-hand with sufficient and effective, properly used personal protective equipment for staff. 

Employers have an obligation to help train doctors working in unfamiliar terrain on sterile techniques, recognition of infectious diseases and transmission knowledge. This and the provision of adequate and proper PPE and giving doctors time to rest via careful rotation of staff raise fresh questions about legal liability.

Hospitals urgently review infection protocols

Meanwhile, average compliance with minimum hand-hygiene standards in all hospitals in South Africa stands at 54%1 – while the public is consuming globally scarce personal protective equipment increasingly needed by healthcare workers.

Experts in the National Department of Health’s COVID-19 Command Centre stress that gold-standard N95 respirators used for aerosol generating procedures, expected to be in far shorter supply once the pandemic takes hold, and single-use surgical gloves, (whose protracted and improper use by the lay public can actually spread infection), are vital to protect South Africa’s thinly-spread healthcare work force.

All emphasised social distancing and hand hygiene, (washing, sanitising), as the pillars of infection control, saying personal protective equipment, while vital, came second, other than for those treating patients at the coalface.

They were approached shortly after Durban’s St Augustine’s Netcare Hospital infection tragedy where the Coronavirus claimed five lives, with 48 of the 66 people infected being healthcare workers. Professor Shaheen Mehtar, former Stellenbosch University infectious diseases chief and lead government advisor on COVID-19 infection control, said there was, ‘no honest-to-goodness reason,’ why such a high proportion of healthcare staff were infected in the St Augustine’s outbreak if the correct infection prevention and control, (IPC), procedures had been followed.

Shortage of qualified infection control

While she’s not involved in probing the tragedy, she suspects insufficient hygiene adherence and possibly sub-standard infection control training were responsible. She emphasised the wider South African context where only 190 healthcare workers hold post-graduate diplomas in infection control. She also questions where the 2 500 people healthcare workers she helped train, are working today.

“I don’t know how well trained the people who write infection control policies for some hospital groups are. Every single healthcare worker should have had at least a five-day course in infection control – and that includes healthcare managers,” she stressed.

Professor Mehtar also sits on the COVID-19 Advisory Committee of the World Health Organisation, (WHO), and founded the Infection Control Africa Network.

Natalie Zimmelman, CEO of the South African Society of Anaesthesiologists, SASA, a large portion of whose members are also qualified trauma and pulmonary specialists (and thus at greatest risk of infection), said there was a global shortage of N95 and surgical masks.

She said the reality was that her SASA members were, ‘nothing short of terrified’.

“What people don’t realize is that for every COVID-19 patient per day, you need between 14 to 20 sets of personal protective equipment. Right now, they’re handing out N95 and surgical masks, impervious gowns, booties and gloves – and using them for the next five shifts. Optimally, this PPE is not re-usable. Every time you leave a hot zone, you take contamination out” she said.

Dr Richard Friedland, CEO of the Netcare Group, told local television news anchors that the biggest lesson from the St Augustine’s tragedy was the need to implement stringent hygiene and safety measures in so-called green (“safe”) hospital zones where non-COVID-19 related emergencies were handled. He stressed the difficulty of detecting the Coronavirus in asymptomatic people, saying the first three COVID-19 confirmed cases at St Augustine’s between March 9th and 14th, were asymptomatic, with no recent international travel records. Netcare had rapidly initiated the shutdown of the hospital with COVID-19 confirmed patients isolated, and others tested and transferred elsewhere.

Public ignorance widespread

Professor Mehtar called for greater infection control accountability. She said television images of suited-up health-support staff spraying down surfaces with liquid containers on their backs showed just how much ignorance existed.

“Doing that is virtually useless – the protection lasts about 20 minutes and the stuff degrades in the sun, not to mention posing a lung-related threat to everybody who breathes it in,” she warned.

She said that when worn together, masks and gloves could actually lead to greater risk of infection among untrained users, because people still touched the mask with their gloves.

Professor Mehtar added; “a glove is designed for single use only while the N95 mask can last 24 hours and the surgical mask 12 hours, but all can carry the virus on their surface as easily as bare skin, the added danger being that the wearer believes they’re protected. The only really effective protection is constantly washing your hands after all potential infective risk contact.  Shopping with gloves on and touching shelves, opening fridge doors and handling products is way worse than having your hands sanitized upon entering and leaving the grocery store.  Social distancing is also a very effective way of reducing transmission.”

Ms Zimmelman stressed that it was offensive to healthcare workers to see members of the public wear the highly effective N95 respirators, which are expensive and in scarce supply.

Crisis if public lionizes protective gear

Scant healthcare workers are an order of magnitude more at risk of getting infected than the general population, so if supplies of personal protective gear run thin and they are forced to further ration equipment, it could precipitate a crisis, Ms Zimmelman added.

By way of illustration she said that if the United Kingdom halved its healthcare workforce it would still have five times as many healthcare workers as South Africa. The Italian hospital recently overrun by COVID-19 infections (62 deaths), had 100 anesthesiologists on hand. In South Africa there were 1 100 anesthesiologists across all hospitals, of which just 250 were in the public sector.

SASA has told their members who are over 60 or pregnant to ‘get off the front lines’.

Ms Zimmelman said that in an ideal world, well-staffed facilities should send some doctors home to be on standby for when their colleagues got sick, so they could rotate them in. She revealed that security manning exits at most hospitals were searching the bags of day patients, visitors and discharged patients to ensure personal protective equipment did not leave the hospital. She and her colleagues recommended that the public use frequently washed cloth buffs to protect their faces, rather than the much-needed masks.

South Africa had not yet reached the stage where everybody was being treated as COVID-19 positive – which is when PPE became appropriate for universal use by healthcare workers. At present surgical masks were ‘probably sufficient,’ unless treating patients who were ‘aerosol generating producers’, (a common phenomenon during procedures inducing coughing, sneezing or the generation of sputum). Then, an N95 (and splash) mask, worn properly, protected the wearer from any incoming germs and was ideal, but it remained inappropriate for taxi drivers or commuters.

Ramping up SA’s response

Professor Barry Kistnasamy, Convener of the National Occupational Health and Safety Committee, said one of his teams was distributing minimum PPE specifications and setting up online training, while another was quantifying actual and projected PPE demand while sourcing and staging supplies. The Department of Trade and Industry was working intimately with the private manufacturing sector to produce PPE such as splash masks, plus ventilators.

“The whole world is after PPE so it’s important to secure supplies and make local plans,” he added.

Ms Zimmelman went further; “It’s like a global procurement war out there. One of our hospital groups had a large consignment hi-jacked by another country en-route here; everybody is scrambling.”

Sagie Pillay, a health economist and the Chief Operating Officer of the Wits Health Consortium, which is providing a secretariat, IT and other intellectual support to the NDOH, said his team was coordinating all PPE suppliers via a centralized process.

“We want PPE distributed in an equitable way across the country, especially with the urban/rural split. Demand currently exceeds supply, with Johannesburg, Durban and Cape Town dominating.”

 He said a national free-access PPE advice portal was also currently under construction.

Sufficient ICU staff vital

With several doctors and nurses already infected with COVID-19, Pillay said it was vital to have sufficient, adequately protected ICU staff available for when the pandemic peaked.

He said there was wide-spread PPE innovation, with some nurses wearing raincoats and manufacturers coming up with low-tech solutions and adapting production lines.
“At a gut-feel level, I think extending the lockdown has been crucial. We’d already lost the first week because of the difficulty in getting some geographic areas to adhere to lockdown – and trouble with SAPS and soldiers complying. Rather we take the pain and buckle down now. Look at how China has come out sooner than anyone else – they will reap the economic benefits. Although a lot of people are volunteering in South Africa, we’re still nowhere near what’s required to respond to the scale of this pandemic. Because our public and private sectors are working so phenomenally well together, we’re responding in multiple partnerships at the same time – and it’s allowing us to see gains. The whole world is saying South Africa is an example to look up to. Our stellar NGO’s have also been providing seamless and vital supplementary services,” he added.

Dr Makuluma urged South Africans to recognize “the critical importance of our doctors and nurses in fighting the pandemic – please do not use PPE which is so vital to protect our healthcare professionals.”

PPE use by the lay public added little or no value to those who could follow social distancing guidelines, were vigilant and adhered to the lockdown regulations to minimize viral spread and the potentially dire impact on an already under-resourced healthcare system, he added.

Written by Chris Bateman

  1. Findings via the WHO self-assessment hand-hygiene kit rolled out across all public and private South African hospitals last year, under the guidance of Prof Mehtar and her team.
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