Does Victoria really have the world’s best PPE guidance for healthcare workers?

Doug Hendrie

14/10/2020 3:46:10 PM

Questions have been raised after Victoria’s healthcare safety chief described the state’s approach as the strongest in the world.

N95 mask
Fit-testing of N95 respirators has been introduced at some, but not all, hospitals in Victoria.

The comments by Safer Care Victoria’s Chief Medical Officer Professor Andrew Wilson come despite a high infection toll among healthcare workers and a new outbreak at Box Hill Hospital.  
‘We have the strongest PPE guidance, as far as I know, in the world, particularly for the N95 masks …  which goes above national guidance, World Health Organization and [US] Centers for Diseases Control guidance,’ Professor Wilson told the ABC.
‘We’re one of the only places I’m aware of where people are wearing them in COVID wards.’
But GPs and top experts have queried that claim, pointing to world-leading nations like Singapore, China and South Korea, which introduced more rigorous personal protective equipment (PPE) requirements from the beginning of the COVID-19 pandemic and have seen very few healthcare worker infections.
By contrast, Victoria had more than 3500 infected healthcare workers during its second wave, with nurses and aged care workers making up most of the cases.
GPs in Victoria have been largely unscathed, with many ramping up protective measures ranging from N95 masks to telehealth.
Victorian health authorities have been belatedly rolling out new infection control measures in hospitals, such as widening the scope of who should use N95 respirators and beginning fit-testing for the masks in COVID-exposed areas as part of a new respiratory protection program.  
Professor Nancy Baxter, who heads Melbourne University’s School of Population and Global Health, wrote on Twitter that the comments suggest Professor Wilson ‘hasn’t fully embraced the risk of airborne infection’.

‘There’s no way we can say our PPE guidance is the strongest in Australia, let alone the world,’ she told newsGP.

‘It’s October and people are just getting fit-tested this week. I get that in March we weren’t ready. But October?

‘You have a million people who have been fit-tested in Australia, the people who work in mines or with silica dust. [For them] it’s mandatory. Look at how hard it’s been to implement fit-testing [for healthcare workers] when it should be standard.

‘It’s very distressing to healthcare workers. I’m a colorectal surgeon and part of the reason I’m vocal on this is that I know some workers have been muzzled. They’re not allowed to say anything. They’re told to tone it down. They’re concerned about their jobs. So if they’re not going to, I have to try.

‘We need to have a very clear vision for how we are going to decrease the risk of contracting COVID for healthcare workers. Given the public health risk, that should be everyone’s number-one concern.

‘If we didn’t have healthcare worker infections, we’d likely be out of lockdown.’

Professor Baxter believes resistance from leaders and infection control staff within hospitals is an overlooked reason for the slow pace of change on matters like fit-testing.  
However, Associate Professor Jane Munro, a member of the Victorian Government’s taskforce on healthcare worker infection prevention – which is chaired by Professor Wilson – has previously told newsGP acknowledgement of aerosol spread and the precautionary principle underpin efforts to prevent further infections.
Professor Wilson has also subsequently clarified his position on PPE and aerosol spread, telling newsGP Victorian standards are ‘amongst the strongest in the world’.
‘Most countries recommend the use of N95 respirators only for aerosol generating procedures in patients with known or suspected COVID-19,’ he told newsGP.
‘In response to emerging evidence, the Victorian guidance was upgraded on 1 August to use Tier 3 PPE [including N95 respirators] in caring for patients with known or suspected COVID-19 infection who are cohorted in wards, intensive care units and emergency departments.
‘At the time, this was, and still is, above WHO and national guidance, and the practice in all other states. The US CDC recently changed its guidance.’
Despite Professor Wilson’s assertions, Melbourne University Associate Professor Alicia Dennis, an anaesthetist and advocate for healthcare worker safety, told newsGP that PPE guidelines are still not strong enough.
‘Airborne spread has not been officially recognised,’ she said. ‘[T]he state guidelines for PPE still do not advise wearing full airborne precaution PPE for all staff in immediate contact with COVID-19 patients.
‘It is important to have all the other controls for workplace biohazards in place, like cleaning and ventilation. But if the last line of defence is deficient, and a defence that is actually needed by staff managing COVID-19 patients, then staff will still get exposed to the virus and get infected.
‘The state and national guidelines on PPE for staff working with COVID-19 patients need to change. Many of us have been asking for this for over six months.
‘Infection-control deficiencies have directly led to the second wave in Victoria, and if these guidelines are not upgraded then there is a very real chance that further waves may occur in the future.’
Geelong GP Dr Eric Hadinata told newsGP that Professor Wilson’s claim is ‘not accurate’ given many other countries have ‘far more stringent PPE guidance’.
‘Singapore [has] extensive preparation for the pandemic, including fit-testing, segregation of staff and a policy that the minimum standard of PPE for any staff caring for a patient with confirmed or suspected COVID-19 infection is a fitted, NIOSH [National Institute for Occupational Safety and Health]-certified N95 respirator, eye protection … cap, gown, and gloves,’ he said.
‘While [Victorian] GPs did not completely escape COVID-19 unscathed, the speciality was under-represented in the proportion of healthcare worker infection, especially considering the front-line nature of the profession.
‘GP clinics are mostly privately run, so we generally have full control over our PPE supply and training and crowd control measures. While the RACGP endorsed the national PPE guidance, they emphasised that they are only minimum standards and encouraged us to take extra precautions as we deem fit – and most of us did.
‘The telehealth system significantly reduced our exposure, especially during the height of the pandemic.
‘The protection provided by the Government – both in hospital and aged care facilities – is a different story.
‘The initial efforts to protect healthcare workers in either settings were lacking. Any improvements made since then have been slow and inconsistent. For example, fit-testing of N95 respirators has been introduced at some, but not all, hospitals.
‘The rationale for not doing this is very confusing, given that the Victorian lockdown is currently estimated at [costing] approximately $12 billion per quarter. Any spending on PPE, testing, tracing or anything else that can stop spread within the healthcare sector … would be money well spent.’
Dr Hadinata said asymptomatic testing of healthcare workers remains inconsistent, with GPs visiting aged care facilities still generally not tested unless they work there full-time.

It has been said Professor Wilson’s comments suggest he ‘hasn’t fully embraced the risk of airborne infection’. (Image: AAP)

Outspoken Melbourne GP Dr Vyom Sharma said the new Box Hill Hospital outbreak demonstrates that the new measures are not yet fully effective.
‘Professor Wilson claimed Australia is one of the only countries where N95 masks are worn on COVID wards. If he truly believes that, we have an officer at the top of the tree out of step with what was happening in Hong Kong, Singapore, South Korea and Taiwan back in February and March,’ he said.
Dr Sharma suggested Australia’s response had an ‘Anglophone bias’, meaning research and methods from Asian nations with previous experience battling the 2003 SARS epidemic had been largely overlooked.
‘We have a massive blind spot. For some reason, we aren’t happy to [introduce measures] until we have Australian experiments and Australian mistakes,’ he said.
‘What was it that prompted N95s for COVID wards? It was the outbreak at the Royal Melbourne Hospital. We should not wait until it occurs domestically and act like it’s a revelation. 
‘Another mistake experts make is they look at the suite of infection control and prevention measures these SARS countries took and question if there is evidence of each. But we don’t look at the whole approach and see how effective the whole suite is – we get bogged down in minutiae.
‘But in a pandemic, an overreaction is precisely what’s needed.’
Dr Sharma described the changes taking place to tackle healthcare worker infections as necessary, but rolling out too slowly.
‘We are on the clock in Victoria. Lockdowns will end, either because the Government will lift them or compliance will fall,’ he said.
‘Then the illusion of infection and prevention control will come crashing down as the prevalence of community transmission rises.
‘Where are the ventilation studies announced well over a month ago? Why is the 31 October deadline for fit-testing now apparently just for the initiation of fit-testing program?
‘Why are we not cohorting staff on COVID wards, so they do not begin a consecutive shift on a non-COVID ward? That still happens.
‘We are continually told not to focus [solely] on PPE because it’s the last line of defence. But where is the progress on all these fronts?’
In the ABC interview, Professor Wilson said the respiratory protection program – which encompasses N95 fit-testing and training, and other measures – was intended to be in place by the end of October, with around 600 staff fit-tested to date at the Northern Hospital, as well as staff at Western Health.
He said he is ‘pretty confident’ that fit-testing is not relevant to the Box Hill outbreak, as affected patients and staff were in a normal ward, not a COVID ward.
‘We’ve seen the [healthcare worker infection] numbers come right down, which is really encouraging … even though we have patients in hospital. Hospital staff had a large part to play in numbers coming down,’ he said.
newsGP has previously reported concerns that waning community transmission may see the slowing of difficult structural changes to prevent healthcare worker infections.
The Department of Health and Human Services was approached for comment and clarification.
This article has been updated to include comments from Safer Care Victoria’s Chief Medical Officer Professor Andrew Wilson. 

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Dr Horst Paul Herb   15/10/2020 5:51:30 PM

When it comes to whatever Australia does or discovers, it always seems to get reported as "world's first", "world's best", and so forth.
The authors seem, at best, look at the anglosphere when looking for comparison and precedents - if that.
Yes, Australia is a great country, often punching above it's weight - but realistically being the "world's best" or "world first" is relatively rare for us and in the majority of cases simply untrue.

As in this example - the author obviously has not visited South Korean, Taiwanese, or Japanese hospitals, where PPE even prior to COvid was often far better than what we are aspiring to at present.