Spiking COVID infections in healthcare trigger urgent calls for better infection control

Doug Hendrie

10/08/2020 4:34:17 PM

The number of coronavirus-infected healthcare workers in Victoria has passed 1000 – and is increasing every day.

GP in PPE taking a swab
Infections among health workers have focused attention on the adequacy of PPE provision throughout the healthcare system.


There are now 1065 healthcare workers across Victoria battling coronavirus, including two GPs who are in intensive care. The spike comes even as the state’s cases show signs of stabilisation, dropping to 322 new cases on Monday 10 August.
Alarmed GPs and physicians have called for immediate efforts to understand when and how the virus is being transmitted to healthcare workers, given the risk to their lives and the broader impact on the health system.

But Professor Andrew Wilson, Chief Medical Officer for Safer Care Victoria, has called for calm, pointing out that only a small number of cases have been shown to be acquired at work and that many are linked to major aged care outbreaks.
Some GPs running respiratory clinics have unilaterally moved to more stringent personal protective equipment (PPE) with N95 respirators and face shields, though official Victorian advice for GPs currently only recommends eye protection and surgical masks.
Emergency physician Dr Stephen Parnis told the ABC the rising number of infected healthcare workers is ‘of profound concern’.
‘We need to understand how and why and where we’re getting infected as a matter of absolute urgency,’ he said.
Laureate Professor Nick Talley, Editor-in-Chief of the Medical Journal of Australia, described the figure as a ‘horror statistic’ on Twitter
‘How much is due to inadequate PPE/inadequate training in its use? A detailed breakdown and explanation is needed,’ he wrote.

Professor Wilson told newsGP his organisation is contacting services with confirmed healthcare worker infections to ‘ascertain potential contributing factors, lessons learned and recommendations for improvement’.
‘The data tells us that only a small proportion of healthcare worker cases are confirmed as being acquired in a healthcare setting. We also know healthcare worker infections are increasing at a similar rate to community infections,’ he said.
‘Many of the healthcare worker infections are associated with aged care. We have also seen clusters in a small number of hospitals.’
Professor Wilson said his team is regularly reviewing and updating PPE guidance. 
‘There is sufficient PPE for all our healthcare workers. We’re providing PPE to all our hospitals and have millions of items of PPE arriving at our warehouse regularly – ready to be distributed to all hospitals,’ he said.
‘We have around 68 million gloves, 19 million surgical masks, two million face shields currently in Victoria’s warehouse ready to be distributed to health services across the state.’
The number of infected healthcare workers has risen sharply in recent days, jumping by 101 in a single day last Friday, which Victorian Chief Health Officer Professor Brett Sutton said was a ‘very concerning number’.
The increase has again focused attention on the adequacy of PPE provision throughout the healthcare system.
Since the pandemic began, GPs have had to supplement official Commonwealth supplies distributed through Primary Health Networks with their own efforts to source vital protection.
Melbourne GP Dr Mukesh Haikerwal told Today that the issue of PPE for GPs is still ‘patchy’ and called on state and federal governments to ensure adequate supplies.
After a reporter raised Dr Haikerwal’s calls in a press conference, Victorian Premier Daniel Andrews said healthcare was provided by a large team of people, some of which the state had direct responsibility for in public hospitals, while the Federal Government would have a ‘much greater role’ for the general practice network.
‘I’m confident that just as we’ve seen with aged care, just as we’ve seen on so many fronts, the public and private sector, everyone is working together as best they can,’ Premier Andrews said.
‘This thing is not static. It changes every day … the provision of PPE is different today with 640 Victorians in hospital than it was a couple of months ago.
‘I don’t want to see anybody affected by this virus. I don’t want to see people who are there to provide care and support for others, I don’t want to see them in harm’s way. The best thing we can do is obviously continue to provide all the protection we can.’

All doctors and nurses at Dr Mukesh Haikerwal’s respiratory clinic are now wearing N95 respirator masks.

Dr Haikerwal told newsGP the infections among healthcare workers suggest to him that surgical masks ‘aren’t cutting it’.
None of Dr Haikerwal’s staff members have contracted the virus to date, though several have had to self-isolate as a precaution.
‘We now have everyone in masks and face shields and perspex for reception,’ he said.
‘The biggest likelihood of a breach now is staff-to-staff in the tearoom, eating rooms, common areas. These are more dangerous than a patient coming in, because you may have your guard down and congregate too closely [in staff-only areas].’
All of Dr Haikerwal’s doctors and nurses are now wearing N95 respirator masks with accompanying face shields.
‘Changing from surgical masks to N95s is not recommended right now in general practice – but it probably should go that way, given we don’t know who has this,’ he said.
‘We need to assume everyone has COVID until proven otherwise.’
Dr Haikerwal said face shields, in conjunction with masks, have proven their worth.  
‘You do a swab and you might think did it perfectly and got away with no spray, but you don’t even know there’s spray coming out,’ he said. ‘When you wear a face shield, you can see it – there’s spatter down your shield.
‘You need the masks as well, they’re the most important part.’
While his respiratory clinic found no cases of the coronavirus during the first wave from April to June, the second wave is very much a reality, with 42 cases confirmed since 3 July.
‘This is game on. This is not a dry run,’ Dr Haikerwal said. ‘This is reality and Victoria is at the pointy end.
‘The level of unknown-source cases is increasing and healthcare workers are on the frontline. We are seeing more of these people and often without symptoms. That leaves us exposed despite triaging.’  
The RACGP is guided by current Department of Health and Human Services (DHHS) advice, which states that all healthcare workers in Victoria should now use eye protection such as face shields, but does not require N95/P2 respirators for Tier 1 workers in areas of higher clinical risk, which covers GPs.
A recent survey of 677 physicians released by the Royal Australasian College of Physicians found that one in five reported sourcing their own PPE, with 45% having limited or no access to N95/P2 masks.
More than two-fifths of the infections among Australian healthcare workers are linked to nurses, who often work in close proximity to COVID patients. newsGP understands that many of these nurses are linked to aged care clusters.

Lisa Fitzpatrick, Victorian branch secretary of the Australian Nursing and Midwifery Federation, told newsGP she is concerned over the links to aged care.

‘The largest number of healthcare workers testing positive are coming from the private aged care sector, with PPE access issues being revealed in many of the facilities experiencing devastating outbreaks,’ she said.

‘There should not be any PPE issues in private aged care. There’s a system in place for providers to access the Federal Government’s national stockpile which seems to be working for the vast majority of facilities.

‘[We have] put every single employer, particularly those private aged care providers, on notice. They must provide appropriate PPE and get their infection control training, systems and practices in order. Anything less is unacceptable.’
GP and remote emergency doctor Dr David Berger has previously claimed in Nine Newspapers that Australia did not prepare appropriately for a wave of true community transmission during the reprieve between the first and second waves.
Dr Berger believes Australia and other anglophone nations failed to learn the lessons about healthcare worker protection from Asian nations such as Taiwan and China.

He told newsGP that while China’s more stringent PPE requirements might seem like overkill, they have been effective, according to research published in the British Medical Journal – a point also made by Dr Haikerwal.
‘China had much higher levels of PPE protection. Basically at any level of risk they will be one step at least above us, from coveralls, powered air-purifying respirators [PAPRs] to double gloving,’ Dr Berger said.  
He said Australian governments cannot leave GPs to ‘fend for themselves’ in staying safe.
‘If this pandemic has taught us one thing it’s that in public health there can be no distinction between public and private providers,’ Dr Berger said. ‘The government needs to support private providers as much as it supports the public system. The virus knows no such distinction.
‘These infections [in Victoria] are a sign of a deficient infection-control regime. Deficiencies in PPE are very real, but they’re a symptom of a wider illness.
‘It doesn’t matter how safe an infection-control regime actually is – if healthcare workers do not feel it is safe and have confidence in it, it has comprehensively failed. The majority have low levels of confidence.
‘So much of this is needless. You have to keep your staff physically and mentally safe and well – you can’t just ignore the fact there are nearly 1100 healthcare workers with an active infection, and the stress that puts on everybody.
‘We’re not far off the point where some people will say, I’m not going to do this anymore.
‘Society has broken a covenant with healthcare workers to look after them, protect them and give them the tools to do the job. If society does that, it cannot expect healthcare workers to take up the slack indefinitely.’
A Department of Health (DoH) spokeswoman told newsGP that PPE access isthe ‘highest priority’ for the Australian Government for frontline healthcare workers.

‘The current supply of PPE into Australia is adequate, with states and territory health departments, and private practices and hospitals, able to access PPE through usual supply chains or through the national medical stockpile under agreed protocols,’ she said.

‘PPE needs by GPs are constantly monitored and reviewed to ensure the available product is supplied and stock is available for GPs through the national medical stockpile.’

The FederalGovernment has distributed more than 20 million masks – surgical and N95 – to Victoria so far, out of a nationwide total of around 60 million.  

‘The appropriateness of N95 use is governed by clinical need. For example, use a P2/N95 respirator instead of a surgical mask for frequent close contact with patients with suspected or confirmed COVID-19, or procedures that generate aerosols,’ the DoH spokeswoman said.

The spokeswoman said the Australian Health Protection Principal Committee ‘regularly reviews’ its position on PPE for healthcare workers, including masks, based on advice from the Infection Control Expert Group (ICEG).

‘The ICEG frequently considers emerging evidence regarding the use of particulate filter respirators, such as P2 and N95 respirators, by healthcare workers, in the context of COVID-19,’ she said.

On Friday, ICEG changed its guidance to advise that N95 masks should be worn when treating suspected or confirmed COVID cases who are exhibiting challenging behaviour, such as shouting.

‘Recent experience in these settings suggests an increased risk of healthcare worker infection, despite apparent compliance with infection control precautions,’ the updated guidance states. 

‘Anecdotally, this increased risk is associated with challenging behaviours, such as shouting, by patients who find instructions hard to follow (eg secondary to cognitive impairment or mental illness), especially in the first week of infection, when viral load may be high.’

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Dr Ian Mark Light   11/08/2020 7:19:58 AM

With months to prepare since the first outbreaks in March the PPE supply has been far below what is safe.
Hospitals telling doctors and nursers and all staff to get N95 masks head visors and gowns” by yourself “ by searching pharmacies or eBay purchases is a deplorable failure of duty of care to workers .
With huge deficit budgets 100 billion dollars plus the Hospitals but also the Health Care Workers themselves ought pool together to purchase all necessary items .
All the causes of spread from lack of fresh air in indoor crowded spaces to PPE and hand washing have to be meticulously checked by teams of workers as in the “buddy” system of checking protective capacity .

Dr Rodney Thomas Street   11/08/2020 7:24:14 AM

Can we sue if we get sick in a unsafe working environment. Still no adequate PPE. Bureaucratic clowns really don’t give a toss about frontline rd in GP land.
I have bought my own through my friendly spray paint shop. Third world management.

Dr Graham William S Cato   12/08/2020 5:33:26 PM

I don't care how many masks and other PPE there are in warehouses and supposedly available through PPN but we have no end of trouble getting adequate supply