Go to any hospital in Malaysia, and it is still common to see healthcare workers walking around without appropriate facemasks inside the facilities, including in the outpatient clinics and wards.
Some hospitals have enforced compulsory facemask policies within their clinical areas. However, hospitals have differing policies on the use of personal protective equipment (PPE). Appropriate PPE use is typically not mandated in non-Covid-19-designated hospitals.
We have heard a fair share of stories in the media on how healthcare professionals have unknowingly managed and even performed invasive procedures (e.g. intubation, surgery) on Covid-19 positive patients without donning adequate PPE. These patients either had no symptoms or failed to disclose their contact history with positive cases or their recent travels.
The million-dollar question is then “Why are we not making it mandatory that all healthcare workers in the country don-up appropriate PPE such as facemasks during this pandemic?”
Unfortunately, the answer is not so straightforward.
There are many policymakers in healthcare who strictly abide by guidelines set by international authoritative bodies such as the World Health Organization (WHO) that strongly discourage individuals including healthcare workers from using face masks when not directly exposed to symptomatic individuals. This recommendation is based on the premise that masks are ineffective against the spread of Covid-19 in asymptomatic individuals.
This argument, however, may no longer hold true in the case of Covid-19, where pre-symptomatic transmission has been increasingly reported. It is therefore conceivable that pre-symptomatic transmission may soon become a major driver of community transmission.
Testing strategies in this country have primarily focussed on individuals presumed to be at higher risks of Covid-19. Malaysia may not have the testing capacity to carry out broader, more comprehensive population-based testing.
There is also currently a global shortage of PPE. As a result, many hospitals may also be rationing the use of N95 masks and surgical masks, reasoning that PPE needs to be conserved and used as efficiently as possible in ‘low-risk’ clinical settings.
This situation is not unique to our country.
The US Center for Disease Control (CDC), for example, recently loosened its guidelines allowing the reuse of single use facemasks and N95 respirators.
Disturbingly, several recent reports from the US indicated that hospital administrators had reprimanded their staff for wearing face masks or other PPE in public areas of the hospital such as corridors, citing that ‘unnecessary use’ of such items may scare patients, or even deemed as ‘not setting a good example for other staff members’.
In some extreme cases, there have also been incidences when US healthcare workers were fired for wearing face masks during routine clinical work that have been traditionally deemed as not ‘high risk’ (e.g. inserting an intravenous line).
We should take a stand to “look East” to countries such as Singapore, Hong Kong, Japan and China who have done well in the current pandemic. They have exhibited judicious yet proper use of PPE such as facemasks.
As emerging evidence is beginning to show a significant role for pre-symptomatic transmission of Covid-19, the use of PPE in all clinical encounters is going to be instrumental to protect Malaysian healthcare workers; including in our non-Covid-19 designated hospitals and wards.
Given the lack of testing capacity and the mild spectrum of Covid-19, many patients may have gone untested given the strict guidelines on testing.
It makes little sense to limit access of healthcare workers to face masks and other PPE such as gloves, in healthcare settings based on their disciplines or specialities, which are arbitrarily delineated as ‘non-front-line’.
It is also nonsensical to rely on a patient’s travel history, or selected symptoms to determine whether protection via a facemask is warranted for the attending healthcare worker. With the establishment of community transmission, we need liberalisation of PPE use in healthcare facilities.
Recognising and acknowledging that this ‘armour’ is needed to protect all healthcare workers across disciplines and sectors, irrespective of whether they are frontliners or not, is a necessary first step in preventing Covid-19 transmission in healthcare facilities.
In Malaysia, a substantial number of healthcare workers, and even entire clinical departments have been placed under quarantine. They are taken off their duties for up to 14 days, due to breaches in self protection as a result of managing asymptomatic Covid-19 patients, being treated for other ailments.
The loss of healthcare workforce due to quarantines, has further strained the already overloaded clinical services in the affected hospitals.
It is a travesty if any healthcare worker is infected in the course of carrying out his or her duty because of a lack of PPE. To quote Dr Peter Slavin, the President of Massachusetts General Hospital, “we wouldn’t want to send soldiers into war without helmets and armour, we don’t want to do the same with our healthcare workers.”
Dr Nirmala Bhoo Pathy is a a Public Health Medicine Specialist and Associate Professor of Epidemiology at the Dept of Social and Preventive Medicine, Faculty of Medicine, University of Malaya
Dr Sanjay Rampal is a Public Health Medicine Specialist and Professor of Epidemiology at the Dept of Social and Preventive Medicine, Faculty of Medicine, University of Malaya. He is also Chair of the Public Health Society, Malaysian Medical Association (MMA)
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