By Dr P. Ramdaursingh
If you don’t sacrifice for what you want, what you want will become the sacrifice.
— Jay Shetty, via twitter.com
The Spanish flu pandemic killed around 50 million people, exceeding the number of people and soldiers killed during World Wars I and II. The frontliners were the soldiers, ones most at risk of dying. But at least they could see their enemy. The frontliners against Covid-19 are health care workers who face an invisible enemy. Thousands of them – physicians, nurses, paramedics — have already got infected by their patients, and hundreds have died. The first victim was Dr Li Wenliang, the ophthalmologist in Wuhan who raised the alarm against coronavirus.
To date, Covid-19 has claimed around 65,000 lives, despite drastic actions worldwide: lockdowns, mass quarantines, travel restrictions, etc.
The statistics are frightening. Across China more than 3300 health care workers have been infected as of early March and, by the end of February, at least 22 had died. In Italy, the virus had infected more than 5000 doctors, nurses, technicians, ambulance staff and other health employees, with 41 deaths. The majority were on the frontline in the badly affected northern regions around Lombardy; they contracted the illness at the start of the outbreak when protective equipment was lacking; this happened in Wuhan too.
More than 3900 health care workers (HCWs) in Spain are reported to be infected. Worldwide, including Mauritius, there is panic and the public are not strictly following the official guidelines and rules. People are loitering around uselessly and the police have limited capacity to take required actions. Government is at a loss, changing strategies every now and then, and is unable to foster trust in the public. Despite the uncertainty and instability HCWs are continuing their battle but seem to have been forgotten.
Their weapons are limited: regular washing of hands, self-isolation when mandated, social distancing, avoiding crowded areas; and if symptoms aggravate to contact their colleagues in hospitals.
Access to personal protective equipment for HCWs is a serious concern. Even developed countries like the UK and USA report extreme shortages, and the situation is worse in parts of the developing world which may be most hit by the pandemic. Many HCWs are forced to put themselves at risk, managing patients using sub-standard equipment. HCWs are overstretched, with no end in sight working in an under-protected, stressful and frightening environment, making them very vulnerable to infection.
If they are not adequately protected, they will end up becoming patients. The following measures will greatly help these soldiers, our ‘Corona warriors’:
Establish triage areas and source control
- Well-trained staff should be placed at entrance of each health care facility, where there should be physical barriers (glass/plastic) to limit contact with potentially infected patients. All patients must be assessed for possible Covid-19 infection. Those who are high risk must be separated and directed to specially designated wards for management by separate medical teams.
- The standard hygiene practices should be reinforced for the general public as well as for the health care workers. These combined with protective gowns for the latter increase the protective effectiveness to 91%.
- Safety measures whilst dealing with OPD/Clinic patients: To avoid crowding and transmission OPD work should be kept to a minimum. Relatives should be allowed to visit Social distancing must be practised – waiting-room chairs placed six feet apart; all patients with respiratory symptoms to wear a mask in the waiting area and instructed on cough and sneeze hygiene.
- There should be good ventilation. Doctor should wear surgical masks, scrub their hands with soap/water and use an alcohol-based disinfectant after each examination.
- Safety measures in hospitalised Covid-19 patients: Ideally, to be cared for in single rooms with adequate ventilation. As their numbers increase, they should be placed in designated wards, on separate floors or in newly- constructed temporary units, with bed spacing of at least 2 meters.
- A dedicated team of medical staff should be assigned to the care of such patients so as to limit transmission and conserve personal protective equipment. They should use N-95 masks, eye protection (goggles) or face shield to prevent contamination of mucus membranes, and wear clean non-sterile long-sleeved gown and gloves.
- Clear instructions on how to store and dispose PPE is essential.
- Relatives and visitors should not be permitted, but stay in touch with loved ones through electronic means.
The important message is: universal precautions of strict hygiene must be adhered to, with N- 95 masks and full PPEs then being conserved for procedures where respiratory secretions can be aerosolized and for known or suspected cases of Covid-19. For medical staff who are inadvertently exposed to a patient who unexpectedly tests positive, a time of exposure must be defined before deciding to place HCWs in quarantine. If this is done after even casual exposure and hospitals shut down, there will be no one left to treat patients.
- Prophylactic drug for HCWs: Hydroxychloroquine is not recommended for the time being.
- For personnel working with positive Covid-19 patients and for those in ICUs, special precautions must be followed for aerosol generating procedures (tracheal intubation, non-invasive ventilation, tracheostomy, etc). These procedures are all associated with increased risk of transmission of Covid-19, and should be carried out in an adequately ventilated room or in ‘airborne infection isolation rooms’, with HCWs in full protective gear as detailed above.
- Environmental and engineering controls ensure adequate ventilation of all health care facilities and proper environmental disinfection. Water and detergent can be used for cleansing environmental surfaces and regularly used hospital disinfectants will suffice. Management of laundry, food service utensils, and medical waste should be performed in accordance with routine policy. Laboratories should abide by biosafety practices and recommended transport requirements.
If proper measures are not taken our Health Care Workers will become patients instead of being soldiers. In some parts of Europe hospitals have run out of masks and have insufficient PPE.
In Mauritius the government has constantly assured the population that we have adequate protective materials to fight Covid-19, and an air cargo of around 254 tons of medical materials is expected soon.
Our frontline soldiers will need all the right protective equipments to sustain the fight which is likely to last a while. They will also need the back-up of ancillary staff to increase the frequency and rigour of cleaning light switches, countertops, handrails, elevator buttons and doorknobs. Such measures can give much-needed reassurance to stressed care givers and protect the public too.
One has to remember that the HCWs provide heroic patient as they battle against this mortal enemy but like soldiers, they too face considerable mental stress. They also do feel the sorrow of loss when their patients succumb to the virus. They too have families, and so will also naturally be fearful that the virus might reach those they love most.
Unfortunately Covid-19 will not be the last dangerous microbe we encounter. And only applauding our health care workers will not suffice. They need protection as well in this war.
The heroism, dedication and selflessness of medical and allied health staff give the rest of us a degree of reassurance that we will overcome this virus.
* Published in print edition on 7 April 2020