Much has been said about the PPE (personal protective equipment) issue and here is my take from the ground, having personally visited and spoken to doctors in about 20 different government health clinics and 12 different government hospitals.
Based on personal opinion and not representing any institution, I hope that what I write will provide some constructive comments in helping us as we fight Covid-19.
8/4/2020 — Health DG: No shortage of PPE, challenge is in distributing them
13/4/2020 — Covid-19: Need more PPE, current supply can only last for two weeks, says Health DG
Why such a big difference in five days? What happened to the electronic system that coordinates PPE for the entire country?
The graph shows more than two months of boot cover supplies left, but most KKM (Kementerian Kesihatan Malaysia) centres are running low in boot covers — many have been using DIY covers. 52 days of head covers left but some are still using plastic bags as alternatives!
I believe the numbers being reported back to the DG of Health is inaccurate. He has been working tirelessly over the past few months — the rest of the country needs to rally alongside and give full cooperation to assist him in fighting this pandemic. Here are some reasons/suggestions:
We need a consensus on infection control guidelines AND agree to adhere to it. Infection control/occupational and safety health units over the whole country (including university hospitals) need to discuss, decide and agree on following certain guidelines.
Within many hospitals, the infection control guidelines are not agreed upon by all heads of units and different departments enforce different practices — this occurs even public university hospitals in the Klang Valley. Even the types and number of layers of gloves to be worn differs from departments within a single center, and differs between centres.
A particular centre has had doctors intubating possible Covid-positive patients without hood covers; while another center performs swabs with Tyvek coveralls and powered air-purifying respirators (PAPRs). Tyvek coveralls have also been used for cleaners and volunteers at registration desks.
Meanwhile another centre has purchased half-face respirators (refer picture) with filters that are wiped, kept and changed every two weeks to conserve N95 respirators.
Some triage counters are dressed up in gowns, hoods and boot covers, despite the guidelines saying that one surgical mask is sufficient as long as triagers maintain their distance with patients. However, triagers at certain centers have no choice but to escort patients into the facility, some even performing CPR. The guidelines need to be modified to cater for situations like this.
A specialist from a government centre claimed that his unit had run out of face shields and that the whole hospital had no stock left. When contacting another department in the same hospital, another doctor stated that there were plenty of face shields left. This reflects the communication breakdown within that particular centre.
Because of the lack of a consensus and failure to communicate, social media and messaging platforms are full of requests from everywhere, from clinics, district health offices, individual wards within a hospital, etc. This is causing much confusion on the ground as non-government organisations (NGOs) have no idea where the real need is.
The lack of standardisation between centres will result in the inaccurate reporting of stock levels to the central coordination center. “Two week supply” left of PPE can mean very different things to different centres!
While trying to save and limit the usage of PPE, there should be no compromise of safety. Rationing can be carried out but without endangering health care workers (HCW) and I am glad that the practice of changing plastic sheets of face shields has since stopped in certain centres.
PPE hotlines have been given out and I urge all HCW not to compromise safety while using PPE — call the hotlines should you run into any shortage or difficulty in obtaining adequate PPE. Please do not wait for your unit/department head, district health office, state health department. The hotlines need real-time information from the ground to enable them to plan and coordinate better.
Certain centres have limited the number of swabs due to the lack of N95 masks — this could affect the number of tests that we run. There is talk of decontaminating and reusing N95 masks — while approved by the FDA this is a fairly new practice and we should tread with caution.
Faulty virus testing kits have been known to be given out by China. Netherlands has recalled masks donated from China due to safety reasons. Masks donated from the China government have been sent out to multiple centers and not all are of the same quality.
Some have loose elastic bands, some have no nose clips at all. All PPE stock that arrives needs to be checked to ensure that proper PPE is being given out to health care workers.
The CDC (US Centres for Disease Control and Prevention) has recognised the GB2626-2006/2019 as alternatives to the 3M N95 respirators — but are we aware that China manufacturers themselves do not agree to that? They have instead suggested that the GB19083-2010 be used as a medical grade mask.
Fit checks have been done for the KN95 GB2626 range of masks and found to have “failed” — but are we aware that both 3M and China manufacturers agree that the Total Inward Leakage (TIL) is around 8% for the KN95 GB2626 range? Therefore, performing a fit check is redundant.
We then need to weigh the pros and cons — decontaminate NIOSH N95 respirators and reuse, or use multiple new KN95 masks? We need to seriously study the different types of masks produced in China should we one day need to rely solely on them. But I pray that we never get to that stage, and that the pandemic settles before the national stock levels of N95 respirators are depleted.
Consider opening all factories/companies that are able to produce PPE to assist in mass production — encourage donation/purchase non-woven fabric to maintain a constant supply. Coveralls from China can be purchased in bulk as a cheaper but non-inferior alternative to Tyvek suits.
It is heartwarming to see many Malaysians rally together to help each other, but let us not forget that DIY PPE can compromise the safety of health care workers.
If you are part of a team that is making PPE to donate, please bring a sample of your cloth/ completed gown/ face shield etc to the health care facility and check with the occupational and safety health/ infection control unit. Only after getting clearance should you proceed with donations and mass production of that item.
Call up the person in charge at the health care facility that you plan to donate to and find out exactly the needs there. Eg: there is a certain university hospital that has tens of thousands of face shields, yet due to administrative delays, requests for face shields are still being made.
It is more beneficial to then contribute face shields to government health clinics which have much lower stock levels. This will also ensure that the time, effort and money that you have put in to collect funds and DIY PPE is used wisely.
Proper coordination needs to be carried out to ensure equal and fair distribution to all, especially health clinics that are often neglected. NGOs need to agree to work together to ensure that there is no overlap in distribution of aid.
Until a nationwide system to coordinate NGOs is developed, I urge all NGOs to work closely with state health departments and district health office in identifying needs on the ground.
Sending PPE directly to the state health department is an option. However many choose to deliver directly to the health care facility for accountability reasons. After delivering aid or PPE to a particular centre, please inform the local health office to keep them updated. Do not neglect government health clinics as they are often overlooked in distribution of aid and PPE.
Meanwhile, wash your hands, don’t touch your face and stay home.
Dr Timothy Cheng is an orthopaedic surgery masters trainee in a local university hospital. He believes in speaking out and standing up for the truth and hopes that Malaysian doctors will put aside differences and unnecessary bureaucracy in the fight against Covid-19.
- This is the personal opinion of the writer or publication and does not necessarily represent the views of CodeBlue.