Why are so many Victorian healthcare workers contracting COVID-19?

Doug Hendrie

21/08/2020 4:37:22 PM

The state’s Chief Health Officer now concedes the majority of these infections are acquired at work, but that leaves one question: How is the virus getting through PPE?

Stressed doctors in PPE
Healthcare workers account for 14% of the more than 17,000 COVID-19 cases in Victoria.

One fact is beyond dispute: 2563 healthcare workers in Victoria have now tested positive to the virus that causes COVID-19.
That represents around 14% of the state’s 17,683 cases.
Earlier estimates by Victorian Health Minister Jenny Mikakos that only 10–15% of healthcare worker infections were occurring at work have now been upgraded.
Victoria’s Chief Health Officer Professor Brett Sutton said on Friday that a forthcoming report from Safer Care Victoria ‘will show the majority are coming from healthcare settings’.
‘What we need to dig more deeply into is exactly how those transmissions are occurring. There’ll be some that are from patient to staff, but there’ll be a number that are also between staff,’ he said.
That revelation raises questions after Safer Care Victoria Chief Medical Officer Andrew Wilson told newsGP on 10 August that ‘only a small proportion of healthcare worker cases are confirmed as being acquired in a healthcare setting … [w]e also know healthcare worker infections are increasing at a similar rate to community infections’.
The latest news is set to supercharge an already fiery debate over how so many doctors, nurses and aged care workers are getting the virus – and what should be done to prevent further outbreaks.
On one side are public health experts like Professor Raina MacIntyre, workplace safety experts and concerned doctors calling for the precautionary principle to be put in place; essentially acting on the side of caution by upgrading protection through mandatory fit-testing of P2/N95 masks through to ensuring hospital break rooms are safe.
On the other are infectious diseases experts and the Federal Government’s key advisory body, the Infection Control Expert Group (ICEG), who say many are assuming the worst – that the virus is being transmitted from patients to workers – when the data on healthcare workers is not in.
They also say evidence for aerosol spread is not substantive enough to recommend P2/N95 respirators as the default, and stress it is likely that significant transmission is occurring when workers let their guard down, such as in break rooms or while removing their personal protective equipment (PPE).
Intensifying the debate is the very real fear and dread among frontline healthcare workers such as hospital doctors and GPs.
‘There is anguish amongst healthcare workers all around Australia. The numbers [of infections] don’t convey the anguish and anxiety. You have no idea. None of us are sleeping properly and we haven’t for months. We have escalating and horrendous healthcare worker infections and they don’t seem to be stopping.’
That is Dr Michelle Ananda-Rajah, a Melbourne physician in general medicine and infectious disease, who recently formed advocacy group Health Care Workers Australia alongside Dr Benjamin Veness.
Their group recently published an open letter as a vote of no confidence in ICEG, which more than 3000 healthcare workers have now signed.
‘We should have taken a much more precautionary approach,’ she told newsGP. ‘The minimum [PPE] should have been an N95 mask that was fit-tested. Otherwise it’s not going to be affected.
‘We are a super high-risk group. If we get it, we end up infecting patients and we bring it home as vectors to transmit to family members.
‘Authorities seem to be accepting this as collateral damage. But that is completely unacceptable.
‘If you knock out healthcare workers, you collapse your system. There’s no clarity over how long it takes to recover and return to work. It’s a false economy to deny healthcare workers top shelf respiratory protection.
‘[ICEG] guidelines have been reactive rather than precautionary in response to these escalating infections.’
Dr Ananda-Rajah’s group wants P2/N95 respirators to be introduced immediately for any care of suspected or confirmed COVID cases, even for non-aerosol-generating procedures. They point to Victoria’s recent move to require respirators for most COVID care as a sign that ICEG-produced federal guidelines – which often require surgical masks only – are not adequate.
Given many of Victoria’s older hospitals have poor ventilation control and cramped working spaces, Dr Ananda-Rajah believes PPE has to be strengthened to offset these issues.
‘In clinics, aged care, hospitals, you have problems with hazard control. It’s often compromised when you’re dealing with ageing infrastructure,’ she said.
‘Old ventilation systems, windows sealed shut – you’re constrained by the built environment. In these cases you have to strengthen PPE.’
Professor MacIntyre recently told newsGP she believes the precautionary principle is ‘warranted to protect all health workers’, who are 3–4 times more likely to contract the virus than members of the public, according to a Lancet Public Health article.
Majority of spread is droplet, expert says
ANU Professor of Microbiology Peter Collignon, who is an ICEG member, told newsGP he understands why people are responding so strongly.
‘All of us would like zero risk because this is an infection that can make you very sick or kill you. But there is no absolute science,’ he said.
‘When you look around the world, the available evidence is that appropriate PPE, including face protection, surgical masks and proper removal can reduce your risk of COVID substantially in normal circumstances.
‘The vast majority of spread appears to be through droplets. So if you wear appropriate PPE – a surgical mask, eye protection and face shields – there appears to be very little transmission.
‘If you look at all the available evidence, a large proportion of the infections that medical staff got was out in the community with friends and family when you have large community transmission. In workplaces, it can occur in tearooms, or if you get too close together.
‘People think if they have N95s, they don’t have to worry about anything else. But having clean zones and dirty zones and proper handwashing and physical distancing matter more.’

Adequate handwashing remains vital to keeping any workplace as safe as possible.

A recent Antimicrobial Resistance & Infection Control article backs this view, concluding:
‘Based on the scientific evidence accumulated to date, our view is that SARS-CoV-2 is not spread by the airborne route to any significant extent and the use of particulate respirators [such as N95s] offers no advantage over medical masks as a component of personal protective equipment for the routine care of patients with COVID-19 in the healthcare setting.’
Another top infectious disease expert, who could not be named due to their position, told newsGP that Victoria’s generalised outbreak means some healthcare worker cases could have been acquired in the community.
‘Testing bias is a major concern. Healthcare workers are probably being over-represented in testing, because the hospitals have zero tolerance for people being at work unwell,’ the expert said.
‘Hospital environments are not very conducive to physical distancing, and there’s also potential for healthcare-worker-to-healthcare-worker transmission that the relentless focus on PPE for patient interactions fails to address.’
Healthcare worker infections raises alarm bells for workplace safety experts
The livewire issue is also drawing in experts from workplace safety.
Since the start of the pandemic, Victorian workplace safety agency WorkSafe has received more than 1050 calls from workers in the health and social assistance sector.
A WorkSafe spokesperson told newsGP that every employer ‘must meet their obligations to protect workers from the risks of COVID-19’.
‘This includes all healthcare sites,’ the spokesperson said.
Australian Institute of Health and Safety CEO David Clarke yesterday published an article calling for an immediate shift to precautionary principles in preventing healthcare worker infections. 
He told newsGP that the ‘large scale outbreaks’ suggest most healthcare workers are contracting the virus in their workplace.
‘Right now, we’re putting our own hospital workers in hospital. Some will die,’ he said. 
‘It beggars belief that disease control advisors aren’t looking at the single greatest statistic available to them – the sheer weight of number of infections of healthcare workers.
‘For health and safety people, the evidence is in: the status quo is not working.
‘Now is not the time for extra research data. Now is the time to use the available higher-level controls – including better PPE – to stop spread amongst healthcare workers.
‘The environment for healthcare workers outside their work is similar to the rest of the population, but their workplaces are among the most hazardous for risk of transmission. Their rates of infection are 100 times the population average. 
‘Logic dictates that the workplace is where they’re being infected, and giving it to other workers and to patients. 
‘Here we have a hazard with many unknown factors. We find the controls aren’t working. What do you do? Sensible worker health and safety practice means that you upgrade controls based on the precautionary principle, then evaluate whether that works.
‘We simply cannot understand the stubborn resistance to this approach, and that resistance is now a contributing factor in transmission.’
Mr Clarke is aware that some Victorian hospitals are still not taking vital precautions such as split-shifting break rooms to avoid potential transmission, or sharing of basic work equipment.
Leading occupational hygienist Kate Cole has called for immediate fit-testing of N95/P2 respirators to come into effect in Victoria, pointing out this procedure is done routinely in the construction industry.
‘Construction workers have more protections right now than healthcare workers. That’s because the construction industry recognises it’s high risk and has to put in place a lot of controls to protect people,’ she told newsGP.
‘Just because it’s a little bit pricey is not a reasonable defence for not providing appropriate protections for your workers.’
newsGP also understands that at least two major Melbourne hospitals have acted independently to upgrade protections for their staff.  
The Royal Children’s Hospital has moved to improve its ventilation systems to ensure air is not recirculated in non-clinical areas, just as it is in clinical areas, in a move suggesting hospital management is taking the aerosol theory of COVID spread seriously – or at least acting in a precautionary manner.
The Royal Melbourne Hospital is planning to upgrade its PPE requirements for staff, including looking at reusable elastomeric respirators and powered air-purifying respirators (PAPRs), which would see the hospital go well beyond Department of Health and Human Services (DHHS) guidelines.
The move comes after a recent COVID outbreak, with a Royal Melbourne Hospital manager noting the infrastructure ‘was never set-up to care for COVID-19-positive patients’.
The DHHS has previously told The Guardian that authorities are ‘monitoring the rise in healthcare worker coronavirus infections and we are doing everything we can to ensure they have access to P2/N95 that fit them best’.
‘Fit-testing is a significant part of healthcare worker safety and it’s important that all health services have a plan to fit-test P2/N95 masks for staff, particularly in high-risk areas,’ the spokesperson said. ‘All Victorian healthcare workers are receiving the recommended PPE.’
The DHHS did not respond to newsGP requests for comment prior to deadline.
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Dr Shobha Balu   22/08/2020 10:27:51 AM

Saddened to learn about COVID19 casualties among health care workers. I hope something gets done to help with better and safer way to combat the virus in health care facilities.

Dr Peter William Rankin   22/08/2020 1:43:12 PM

A friend of my son caught Covid working in Northern Emergency Department his story was on the ABC on Thursday when he and his wife were interviewed yet DHHS cites “privacy concerns”
A strange phrase to disguise a lack of transparency as usual we will get an inquiry that will decide after somebody dies we should have done more.

Dr Ian Mark Light   22/08/2020 1:56:57 PM

The evidence is that face shields that cover the eyes and face have to be worn with a mask .
If you cannot get a fitted N95 double surgical mask could be tried depending on tolerability .
You also need gowns that cover the neck and head and double gloving .
The system of having an observer watch a colleague put on and take off PPE is essential .
In a ward a few observing nurses ought be assigned to check for danger procedures even on the normal ward and in emergency .
I would not throw away the fresh air ventilation theory and in some hospitals windows can be partly opened even with Airconditioning on .
There are triage tents with virally filtered air conditioning systems .

Dr Julia Gan   22/08/2020 11:34:11 PM

? Failure of staff or failure of infection control protocols? How can health care workers stay safe? Health care organisations can change work practices & change the way they use their staff, eg separate teams, short shifts - PPE on > no break until short shift finished > at end of shift take PPE off. Is there anywhere to safely doff PPE and have a shower? What is ratio of staff to toilets & are they cleaned & disinfected after each use? Are break rooms, kitchen facilities & equipment disinfected regularly? Where can staff eat their meal & also be Covid safe? Is the work environment disinfectable ?Is there building cross-ventilation, easy-clean floor coverings & chairs? Costs less to prevent infection than to have to replace most of your workforce after they get sick.

Dr Peter James Strickland   23/08/2020 1:24:32 PM

It should be obvious ---the PPE IS effective in protecting health workers ---they are being contaminated as they take it off, and need to decontaminate by showering and clearing and cleaning their hands, face and nose etc of potential virus before leaving their hospital, medical practice, testing site etc. , AND not wear their home-going clothes whilst working, but gowns that can be sterilised time after time. This is a basic of all NBC decontamination, and should be followed rigorously. Are they doing it everywhere?
It is also obvious that almost all contamination happens from indoors activity, and to suggest that aerosol droplet contamination from infected coughing or sneezing Covid 19 patients is minimal seems absolutely ludicrous. Virus to PPE from patient, take off PPE gloves, capes, masks etc --- virus on hands, face, clothes ---wipe nose or mouth of sweat or saliva---contamination of health-worker ---transmission to others, including families and possibly other patients.

A.Prof Christopher David Hogan   29/08/2020 6:08:42 PM

This should not be a surprise- look at the infection rate for medical staff during SARS.
Most medical staff are trained in preventing patients being infected by them, not getting infected by patients. It is a different process & we are not usually rehearsed in it.
Working in an infected area needs training & supervision. It is easy to break protocol when tired, busy or distracted.
It is easy to break protocol when removing PPE & almost everyone forgets, at least once, that shoes can be contaminated (Heavy droplets fall to the ground)>
Add to this the risk of dealing with sick, distressed or demented patients who grab at you- well, it is a nasty situation.
When I was trained in the use of CBR equipment, we were constantly reminded of these dangers.

A.Prof Christopher David Hogan   29/08/2020 6:10:20 PM

NBC - nuclear, biological & chemical is also known as CBR- chemical, biological, radiation