REGISTRO DOI: 10.5281/zenodo.8109823
Josivane Quaresma Trindade1
Marcos Miranda Rodrigues1
Marcos Jessé Abrahão Silva2*
Karla Valéria Batista Lima2
Luana Nepomuceno Gondim Costa Lima1,2
Abstract
Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) was detected in China in December 2019 and generated millions of cases of infection and death worldwide through coronavirus disease 2019 (COVID-19), being decreed by the World Health Organization (WHO) in March 2020 as a pandemic. Health professionals are constantly exposed to contamination due to the nature of their work and therefore must make adequate and continuous use of Personal Protective Equipment (PPE). The purpose of this work was to review data on exposure and protection regarding the availability and adherence of PPE for health professionals in different countries during the pandemic. A systematic review was carried out through selected literature from 2020 to 2022 through the LILACS, MEDLINE, Coleciona SUS and BDENF-Enfermagem databases (via the VHL portal), with the following descriptors (DeCS): “COVID- 19”, “Individual Protection Equipment” and “Health Professionals”, through the Boolean operator “AND”. This systematic review was registered in PROSPERO (CRD42023431481) and performed according to PRISMA guidelines. A total of 24 articles were selected for the analysis of this review. Data indicated unavailability of training, scarcity, poor quality and reuse of PPE, as well as low adherence by health professionals. The highest risk of biological exposure was evidenced in these professional classes due to the absence of PPE in the analyzed countries.
Keywords: COVID-19. Health Personnel. PPE.
Introduction
Currently, the COVID-19 pandemic, caused by the new coronavirus (SARS-CoV-2) is one of the greatest health challenges for all nations in the world, affecting the population on a global scale. The new disease poses a challenge in the application of strategies, as insufficient knowledge about the pathogenic agent SARS-CoV-2, its high speed of dissemination and the ability to cause death has generated fear and countless uncertainties (WERNECK; CARVALHO, 2020).
Health professionals work 24 hours a day in direct contact with patients contaminated by COVID-19, administering care with the aim of combating the symptoms of the new disease. They have a work routine characterized by exhaustion and unfavorable working conditions, threatening their health, safety and well-being. This context was aggravated by the state of public calamity due to the COVID-19 pandemic, as the workload increased with numerous occurrences of severity in the shifts, increased feelings of fear of contamination and unfavorable working conditions due to the shortage of equipment. Personal Protection Equipment (PPE) (SPAGNOL et al., 2020).
In facing the COVID-19 pandemic, the use of PPE is essential, as health professionals are exposed to a disease transmitted by respiratory and bodily fluids. Investment is also necessary through the implementation of protocols, qualification and training of health professionals on adherence and proper handling of equipment, as well as on the management and care of infected patients (OLIVEIRA et al., 2020).
Previous experiences of events similar to the COVID-19 pandemic show that there are numerous impacts on health professionals, such as: increased workload, exhaustion due to the great physical overload, deficiency in the quantity and quality of personal protective equipment, high transmissibility of the disease in the hospital environment and the need for strategies aimed at solving problems in the health work environment. It is in this pandemic environment that health professionals face a challenge they have not yet experienced, as they are constantly under pressure to care for patients in a scenario where there is a virus with a high transmission power between humans, therefore these professionals assume great importance in combating the front line of this new global emergency disease (DOS ANJOS et al., 2021).
This study started from the identification of the guiding question: “What is the availability and adherence of PPE for health professionals in different countries?”. Its objective is to evaluate the exposure and protection of health professionals relating to availability and adherence to PPE. The study is justified by the need to know the exposure and protection of health professionals, which are so important during the COVID- 19 pandemic, because without their workforce, both in terms of quality and quantity, countries would not be able to win the battle against epidemics and pandemics.
Methodology
This study is a systematic literature review on the topic addressed. The selection of articles was carried out in the period from 2020 to 2022 through the databases: Latin American Literature in Health Sciences (LILACS), Medical Literature Analysis and Retrievel System Online (MEDLINE), National Collection of SUS Information Sources of Brazil (“Coleciona SUS”) and Nursing Database (“BDENF-Enfermagem”), via the regional Virtual Health Library (BVS) portal.
The methodology of this study followed five stages, in the first one the guiding question was identified: “What is the availability and adherence of PPE for health professionals in different countries?”. It was carried out with the help of the PICO strategy: Population (P): health professionals; Intervention (I): evaluate the exposure and protection of these professionals from the perspective of the use of PPE; Comparison (C): compare availability and adherence to PPE by these professionals; Outcome (O): impact on the worker’s health.
In the second stage, the following descriptors were used: “COVID-19”, “Personal Protective Equipment” and “Health Professionals”, through the Boolean operator “AND” and indexed in the DeCS (Health Sciences Descriptors). In the third, the ordering of the research was carried out, which resulted in a list of articles, using the filters: full text, main subject, type of study, language and period of publication.
Inclusion criteria were national and international articles, in Portuguese and English, with full text and available free of charge, corresponding to the period from 2020 to 2022 and involving the objective of the research. Publications that did not present the full text and made available free of charge, theses, standards and technical reports, articles that after reading the abstract did not meet the objective of the proposed study, in addition to publications that are repeated in the databases, were excluded. Data selection and extraction were performed independently by two investigators (JQT and MMR) and disagreements were resolved by consensus. The information extracted from them were: author and year of publication; objective; study design; country; results.
The Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Analytical Cross-sectional Studies (ranging from 0 to 8), JBI Checklist for Case-control Studies (ranging from 0 to 10), JBI Checklist for Cohort Studies (ranging from 0 to 11), JBI Checklist for Text and Opinion (ranging from 0 to 6) and Qualitative Researches (ranging from 0 to 10) were used to conduct the quality appraisal. Only when the conditioned answer was “Yes” were the points for answering the checklist questions taken into account (AROMATARIS; MUNN, 2017). It was done independently by two investigators (JQT and MMR) and disagreements were resolved by consensus.
The fourth stage proceeded with the characterization and systematization of the results, ending with the fifth stage through the discussion and interpretation of the data followed by their presentation and discussion. The selected literatures are in accordance with the five-step process described and were presented according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) 2020 method (PAGE et al., 2021). This systematic review was registered in PROSPERO (CRD42023431481).
Results
This study identified 53 articles, all belonging to the Virtual Health Library (BVS) database. However, 25 were excluded for not being consistent with the purpose of the study, 03 were excluded for being duplicated and 01 for being incomplete. Thus, the evaluations of the complete articles followed, resulting in 24 articles that met the inclusion criteria (Figure 1), whose characteristics of the studies were described in Table 1.
Figure 1. PRISMA flowchart for selecting articles. Belém-PA, Brazil (2022).
Table 1. Distribution of files found from the database search.
| AUTHORS | STUDY OBJECTIVES | KIND OF STUDY | COUNTRY OF THE STUDY | RESULTS | JBI SCORE |
| (CRUZ NETO et al., 2022). | Investigate the use of Personal Protective Equipment in the face of Covid-19. | Qualitative Research | Brazil | In this study, 80% of the professionals fully adhered to PPE and also reused the equipment frequently, this is due to the lack or insufficient transfer of equipment reported by more than 50% of the health professionals. | (10/10) |
| (HAEGDORENS et al., 2022). | To investigate the impact of availability, training and correct selection of personal protective equipment on the incidence of SARS-CoV-2 infection or suspected, positive cases in healthcare workers during the COVID-19 pandemic in Belgium. | Cohort | Belgium | This analysis made it possible to infer that health professionals adhere to PPE even with insufficient training. Half of the home care professionals declared a lack of PPE while most of the hospital network servers declared sufficient availability. | (10/11) |
| (AL YOUHA et al., 2021). | To assess factors associated with SARS-CoV-2 infection among healthcare workers. | Cross-sectional survey | Kuwait | Most health professionals in this study adhered to at least three PPE during the care of COVID-19 cases, even with insufficient training. It was also reported that different items of PPE were available all or most of the time. | (8/8) |
| (SMITH et al., 2022). | To investigate rates of correct use of personal protective equipment (PPE), hand hygiene and physical distancing in UK healthcare workers who were in their workplaces at the onset of the Covid-19 pandemic and factors associated with adherence. | Cross-sectional study | UK | Among the participants in this study, 80% reported completely adhering to the use of PPE, this is due to the availability of all the necessary equipment and the receipt of adequate training aimed at safety at work during the Covid-19 pandemic. | (8/8) |
| (MAIER; KANUNFRE, 2021). | To explore the knowledge and use of personal protective equipment by Primary Health Care nursing professionals during the Covid-19 pandemic. | Cross-sectional study | Brazil | This research identified that health professionals make use of all personal protective equipment and that there is not enough training for the correct handling and use of PPE. Scarcity and reuse of available PPE was also identified. | (7/8) |
| (NATH et al., 2021). | To assess the capacity building and safety measures of health workers in Bangladesh who have been exposed to Covid-19 and identify factors associated with respondents’ self-reported participation in capacity building training and their practical safety. | Cross-sectional study | Bangladesh | In this study, it was possible to understand that most of the health professionals in the analyzed population use PPE and half of this sample declared insufficient availability and training for the correct use of the equipment. | (8/8) |
| (ZANGOUE et al., 2021). | To investigate the seroprevalence of IgG and IgM antibodies to Covid-19 among health professionals, as well as to identify the factors associated with this seroprevalence . | Cross-sectional study | Iran | The results of this study showed a high level of adherence to the use of PPE among health professionals, highlighting face masks and gloves as the most used. | (8/8) |
| (MUZE et al., 2021). | Assess the availability and adequacy of personal protective equipment and training status of health workers on Covid-19 in the Silt Zone, southern Ethiopia. | Cross-sectional study | Ethiopia | This study identified that Most respondents reported not adequately adhering to PPE, especially masks, justifying that these supplies were not inadequately available. | (8/8) |
| (EL-SOKKARY et al., 2021). | To characterize the pattern of PPE use among healthcare workers (HCWs) during the first wave of coronavirus-2019 (COVID-19) illnesses in Egypt and to determine factors associated with adherence to appropriate PPE use. | Cross-sectional study | Egypt | The data from the study in question show that on average 60% of the study participants complied with the proper use of masks and gloves, only 30% complied with adherence to other PPE. Most participants reported scarcity and prolonged use of various protective equipment. | (8/8) |
| (MOKHTARI et al., 2021). | Investigate the factors that interfere with the use of PPE from the perspective of nurses who care for patients with Covid-19 | Cross-sectional study | Iran | Through this analysis, it is concluded that health professionals frequently adhere to personal protective equipment when available. | (8/8) |
| (SEITZ et al., 2021). | To examine knowledge, attitudes and practice regarding personal protective equipment (PPE) among healthcare professionals (HP) during the Covid-19 pandemic. | Cross-sectional study | Georgia | In this study, most respondents reported that there is sufficient PPE available to meet hospital demand and use them in compliance with safety protocols. | (8/8) |
| (AL ABRI; AL ZEEDI; AL LAWATI, 2021). | To identify factors associated with Covid-19 infection among healthcare workers in the province of Muscat , Oman, as well as to assess adherence to infection prevention and control (IPC) measures. | Cross-sectional study | Oman | Most of the professionals involved in this research followed the practices and adherence to PPE according to the recommendations and safety protocols for Covid 19. Also, most professionals reported that PPE was always or most of the time available for professional use . | (8/8) |
| (NESS et al., 2021). | Understand the challenges faced by healthcare professionals caring for adult patients during the Covid-19 pandemic. | Qualitative Research | USA | This study reports that one of the challenges faced by health professionals refers to the shortage of personal protective equipment, as well as its reuse and poor quality. | (9/10) |
| (KIM et al., 2021). | To assess the risk, severity and duration of COVID-19 in relation to access to PPE in at-risk healthcare workers (HP). | Cohort study | UK, Germany, France, Italy, Spain and USA | In the analysis of the six countries, it was possible to conclude that limited access to PPE is associated with a significantly higher risk of contracting Covid-19 for health professionals exposed in several countries. | (11/11) |
| (HOERNKE et al., 2021). | To report frontline healthcare workers’ experiences with personal protective equipment (PPE) during the Covid-19 pandemic in the UK. | Qualitative Research | UK | In this study, it can be understood that health professionals reported high adherence to PPE. However, there were reports of unavailability, poor quality and reuse of equipment. | (9/10) |
| (HAKIM et al., 2021). | To assess access to personal protective equipment (PPE), availability of adequate information about PPE use, self-reported ability to correctly use and remove PPE, and risk perceptions associated with C ovid-19 among healthcare workers in the frontline in Pakistan. | Cross-sectional study | Pakistan | The health professionals involved in this study reported using PPE when available, but it was evidenced that more than 30% of these professionals reported not having access or occasionally having access to the equipment, as well as frequent reuse due to the demand for health care. | (8/8) |
| (PICHÉ-RENAUD et al., 2021). | To capture the perspectives of healthcare professionals (HP) on coronavirus disease 2019 (Covid-19) and infection prevention and control (IPAC) measures implemented during the initial phase of the Covid-19 pandemic. | Cross-sectional study | Canada | The health professionals in this study reported making regular use of PPE and more frequently after training and due to the pandemic. The availability of PPE was not clear in the study, only the concern of its scarcity on the part of health professionals. | (8/8) |
| (AGRAWAL et al., 2021). | Evaluate preventive practices followed by healthcare professionals and identify reasons for suboptimal adherence. | Text | India | The professionals in the aforementioned study reported adherence to 80% of the protective supplies, however there were mentions of the unavailability and reuse of PPE. | (6/6) |
| (DAL PAI et al., 2021). | Find out about the repercussions of the Covid-19 pandemic on the work and health of Customer Service professionals Mobile Emergency Service (SAMU) in a capital in the southern region of Brazil. | Qualitative Research | Brazil | Health professionals reported adhering to PPE even without adequate training and quality. Difficulty in transferring and reusing protective equipment was also mentioned. | (7/8) |
| (MARTIN-DELGADO et al., 2020). | Investigate the needs of health workers and the technical difficulties faced by them during the initial outbreak. | Cross-sectional study | Brazil, Colombia, Ecuador. | In this study, it was possible to identify insufficient adherence and serious shortages in relation to personal protective equipment for health professionals in Ecuador, Brazil and Colombia. | (8/8) |
| (COTRIN et al., 2020). | Compare the impact of the Covid-19 pandemic on health professionals: doctors, nurses and dentists, regarding workload, income, PPE, training, behavior, feelings and level of anxiety. | Cross-sectional study | Brazil | This research showed that health professionals maintained complete adherence to all available PPE and that there was limited access and reuse of essential equipment during work activities. | (8/8) |
| (MCGARRY; GRABOWSKI; BARNETT, 2020). | Describing nursing home access to PPE and personnel and examining facility characteristics associated with shortages in these areas. | Qualitative Research | USA | In this research it was found that health professionals working in nursing homes reported a severe shortage of PPE and health personnel. | (9/10) |
| (ZHAO et al., 2020). | To assess PPE use among 3,476 healthcare workers who completed 14 days of quarantine after providing healthcare for Covid-19 patients in Hubei Province. | Cross-sectional study | China | In the analysis of the study in question, it could be concluded that almost 100% of the professionals adhered to all personal protective equipment, and the need for emergency stocks of PPE to avoid shortages was also mentioned. | (8/8) |
| (DELGADO et al., 2020). | Assess the reality and perceptions of personal safety among health workers in Latin America. | Cross-sectional study | Latin America | This study indicates that health professionals in Latin America had limited access to basic personal protective equipment (PPE) during the Covid-19 pandemic. 🇧🇷 | (8/8) |
Discussion
Through the studies related to this review, it can be highlighted that health professionals adhere frequently or most of the time to PPE, even though in numerous reports the unavailability of training, scarcity, poor quality and reuse of PPE was evidenced. However, in two studies low adherence was identified and four did not mention the frequency of adherence by health professionals.
Health institutions must make available all the appropriate PPE to ensure safe work procedures during health care, as well as require their use and offer guidance and training on correct handling. The National Health Surveillance Agency (ANVISA) recommends that goggles, face shield, surgical mask, apron, procedure gloves, cap and N95 mask are the main PPE that should be used by health professionals during assistance where it involves carrying out procedures of an unhealthy and dangerous nature (EM SERVIÇOS; DE VIGILÂNCIA, 2021; WORLD HEALTH ORGANIZATION, 2020).
Chinese health professionals reported that several factors make it difficult to adhere to Personal Protective Equipment while caring for patients with Covid-19, including: reduced dexterity, difficulty viewing, communication obstacles, risk of contamination during dressing and undressing, respiratory discomfort, fatigue, skin lesions and insomnia (DUAN et al., 2021).
A study provides guidance on the purpose and use of the various Personal Protective Equipment and makes reference to the importance of using them by health professionals, as well as maintaining protocols and updating training aimed at better adherence to the equipment so that professionals work in accordance with national and international health recommendations (DE SOUSA NETO; BORTOLUZZI; DE FREITAS, 2020).
Based on the results obtained from this systematic review, it is possible to support evidence that during the COVID-19 pandemic there was a deficiency in the availability of PPE in different countries, characterizing this index as low to severe, only six studies in this review mentioned high availability of PPE and in three studies it was not clear the frequency of availability.
And in this scenario of difficulties, health professionals needed to act on the front line in the fight against the SARS-CoV-2 virus, administering intensive care in the care of COVID-19 cases and in the application of protocols and safety measures against the new disease. Thus, these professionals were more exposed to infection both due to the characteristics of the nature of their work and the unavailability of PPE and training in safety protocols (PERIUS DE BRITO et al., 2022).
Studies have shown that since the beginning of the COVID-19 pandemic, there has been a significant increase in the consumption of Personal Protective Equipment, essential for the care of suspected and confirmed cases of the new disease, requiring the articulation of epidemiological surveillance bodies at national and international level to the execution of procedures aimed at monitoring the lack of equipment needed to prevent the pandemic (SARAIVA et al., 2020).
In a study carried out in Brazil, a growing increase in the use of PPE during the first two months of the pandemic, compared to the previous two months, can be seen. This high worldwide shortage of PPE is due to China, the world’s largest producer of this input, being the epicenter of COVID-19, which has jeopardized its production and sale to the various countries affected by the pandemic (DA SILVA et al., 2021).
Still on the shortage of PPE, low- and middle-income countries suffered inequalities in the supply of supplies due to increased demand and high prices of products. High-income countries, on the other hand, strive to ensure a greater amount of PPE and invest in the implementation of technologies aimed at the reuse and decontamination of materials. And in this world scenario of inequalities related to the acquisition of hospital supplies and the provision of services, health professionals have their safety compromised on a global scale (GARBER et al., 2020).
The shortage of PPE during the pandemic occurred worldwide, causing competition for PPE and respirators for the market in several countries. In this sense, during global disasters such as COVID-19, countries are expected to face shortages and shortages of materials and equipment that are essential for the safe work of health teams. However, difficulties in accessing and using adequate PPE contribute to increasing the exposure of health professionals to biological risks and, consequently, impairing their protection during their work activities (HELIOTERIO et al., 2020).
The failure of COVID-19 virus containment measures through the unavailability of PPE and training of health professionals was evident from the beginning of the pandemic, causing health professionals to be highly exposed to the virus without the guarantee of a safe environment to carry out their work activities. Therefore, it is of fundamental importance to follow the protocols and recommendations established by Organs competent health bodies, aiming at the protection of these professionals in the work environment (DA ROCHA et al., 2020).
This review showed that the lack of PPE during the COVID-19 pandemic was of an international nature, and that in several countries health professionals have denounced the lack of these supplies, as well as their poor quality, inadequate use and lack of training for them. its use. Thus, this review concludes that during the COVID-19 pandemic, health professionals carried out their work activities in a scenario of great exposure to biological risks and less maintenance of preventive measures that involve biosafety habits aimed at protecting the health of these professionals whose importance is evident during the pandemic.
Conclusion
The COVID-19 pandemic brought visibility to the actions of health professionals who play a fundamental role in combating the new disease, becoming the foundation of the health system. In the studies related to this review, the main challenges faced by these professionals during their work routine can be highlighted. It can be concluded that during the COVID-19 pandemic, there is a permanent shortage of PPE in different countries, as well as the need for health professionals to adhere to protective equipment, as well as the implementation of prevention and protection measures through of protocols and training aiming at the qualification of health professionals. Thus, it is expected that these professionals intensify adherence to PPE following safety standards and protocols and that these are made available in quantity and quality through the competent bodies so that health professionals carry out their work activities with the guarantee of greater protection and safety less exposure to biological risks.
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1Graduate Program in Epidemiology and Health Surveillance (PPGEVS), Evandro Chagas Institute (IEC), Ananindeua, Pará, Brazil.
2Bacteriology and Mycology Section (SABMI), Evandro Chagas Institute (IEC), Ananindeua, Pará, Brazil.