A response to ‘PPE for SARS-Cov-2 and the utility of single-use aprons’
In October 2021, the Journal of Paramedic Practice published a comment article from Wesley Howarth, titled ‘PPE for SARS-Cov-2 and the utility of single-use aprons’ (Howarth, 2021). We would like to thank the author for highlighting some evidence and presenting his view on this important topic during the pandemic. However, we would like to provide our response, sharing our views from an infection prevention and control (IPC) perspective.
Firstly, the author suggested that ‘the wearing of plastic aprons with COVID-19 positive patients may be unjustified, provided the patient is wearing a facemask’. We felt that this is a bold statement as the article did not present a strong argument either for or against the use of aprons in the prehospital setting. We appreciated that the evidence on the use of personal protective equipment (PPE) in the prehospital setting is limited at the moment; further research is required to identify the optimal PPE staff should be using in the prehospital environment. We believe that the finding of Howard-Jones et al (2021) was inappropriately used to infer that there is no transmission risk from a uniform contaminated with COVID-19. These concerns stem from the fact that patients that we see as paramedics and health professionals are often older, with comorbidities and are sometimes immunosuppressed. We recommend that ‘precautionary principles’ (Gollier and Treich, 2013) be applied here and apron use should continue despite the uncertainty around their use as PPE during the COVID-19 pandemic. Risks of contamination of uniform from direct contact of undifferentiated patients remain high with the current prevalence of COVID-19 in the UK.
Secondly, we suspected that single-patient-use aprons were under-used in the prehospital settings pre pandemic. The National Institute for Health and Care Excellence (NICE) (2012) recommended that aprons should be used by healthcare workers if there is a risk that clothing may be exposed to blood, body fluid, secretion or excretions and this was echoed by the Royal College of Nursing (RCN) (2017) and the EPIC3 (Loveday et al, 2014) guidelines, which both advise that aprons should be worn whenever there is a risk of contamination of uniform or clothing with blood and body fluids and when a patient has a known or suspected infection. Given that the majority of patients that we come across in prehospital settings would likely fit into one of these categories, aprons should be worn when providing close-contact care during attendance with these patients in prehospital environments.
Finally, we agree with the author that the main mode of transmission of COVID-19 is via respiratory droplets and that face masks are important PPE to protect health professionals against COVID-19. However, it would be reckless to dismiss the utility of aprons as an element of PPE because it would be impossible to rule out the probability of contact and fomite as possible modes of transmission, especially as they often occur simultaneously. This was echoed by the World Health Organization (WHO) (2020), which suggested that respiratory droplets from infected individuals can also land on objects, creating fomites (contaminated surfaces). They therefore advocated the use of contact and droplet precautions by health workers caring for suspected and confirmed COVID-19 patients, and the use of airborne precautions when aerosol generating procedures are performed. We urge paramedics and other ambulance clinicians to continue with the current PPE guidance issued by UK Health Security Agency (UKHSA) (2021) (in conjunction with the Association of Ambulance Chief Executives) as they are being reviewed by IPC experts regularly and emerging evidence will be incorporated as part of the regular review process.
I would like to thank Tang et al for their letter in response to my comment article. Here I will aim to respond to the points raised. Fomite transmission is absolutely a risk factor and this article aimed to highlight the potential discrepancies between the ease of transmission from a plastic apron versus clinician uniforms. For example, as discussed, it could be argued that contaminated droplets landing on a plastic apron are more easily transmittable via direct contact when compared to a fabric surface, which absorbs said droplets. Combine this with the virus' poorer survivability on fabric versus plastic, it could be reasoned that the strength of any present virions and subsequent levels of transmission may be higher compared to clinician uniforms alone. This risk could be further reduced if infected patients are wearing simple facemasks, which are shown to significantly reduce the spread of respiratory droplets in the first instance. As for aerosol transmission, if a patient is potentially infected or symptomatic, alongside wearing a facemask, clinicians could don level 3 masks or respirators to address this risk, especially for ambulance clinicians dealing with patients for prolonged periods in often confined spaces. The precaution principle is valid, and it is a good point raised to compare other similar respiratory conditions; however, its application must also be justified with suitable evidence specific to SARS-Cov-2. As mentioned in the article, an increasing number of patient interactions are now non-COVID, and consideration should be given to whether plastic aprons are appropriate for these asymptomatic individuals, where questions about risk/benefit could be raised.
Current evidence on the use of personal protective equipment across prehospital settings is limited and requires attention
It is true that plastic aprons have formed a part of level 2 PPE pre pandemic, and rightly so in situations such as those involving significant risk of exposure to blood products or emesis for example. This is why aprons are often donned by ambulance clinicians attending childbirths at home. The point the article aims to tackle is whether the standing level 2 PPE, particularly aprons, are appropriate specifically for preventing or significantly reducing transmission of SARS-Cov-2. The conclusion, states: ‘…where full level 2 PPE often remains protocol….’, addressing if in part the fact that many trusts require level 2 PPE for all patient encounters, and that clinicians should follow their own trust's protocols. The apparent risk to vulnerable service users is not questioned; however, if the risk of transmission to such individuals from clinician uniforms is so great that every incident requires clinicians wear PPE to protect them against SARS-Cov-2, if the points raised in the article have any validity, then any suspicion of COVID-19 should prompt a Tyvek suit be donned instead. I say this as aprons do not cover a lot of a clinician's person, and if working outside as ambulance staff often do, these aprons are blown about considerably; it could be argued that this compromises their effectiveness. On the face of it, a superior level of protection here could be advocated for, such as the current level 3. However, this has not been observed in my findings; instead, this raises the question personally of whether the risk of transmission is as great as hypothesised. The article does address that there are no direct comparisons between aprons vs no aprons for SARS-Cov-2 and that such a lack of evidence itself requires attention.
The article ends encouraging clinicians to follow their trusts' respective protocols and policies regarding PPE. It did not intend to promote bad practices, nor does it infer that clinicians should ignore current guidance on COVID-19 PPE standards.
From personal experiences and research into the topic, it was my summarised opinion that the evidence supporting the use of plastic aprons specifically pertaining to SARS-Cov-2, be reviewed (which you quite rightly point out is constantly ongoing). The article also concludes that the current evidence supporting their use be actively made available to frontline clinicians. I would like to add that I am not an expert, nor experienced researcher, but simply an inquisitive, open-minded clinician. My article does not represent evidence in and of itself, and I encourage others to do their own research and to always strive to follow best practice.