The Urologist, Personal Protective Equipment (PPE) and COVID-19 A review of current challenges around the use of PPE as well as measures to reduce the risk of nosocomial COVID-19 transmission

Main Article Content

Subhabrata Mukherjee
Vasileios Bonatsos
Asif Raza

Abstract

Background and Objective
To review the literature from a urologist’s perspective regarding the use of Personal Protective Equipment (PPE), associated challenges, and other potential measures that can be taken to reduce the risk of nosocomial COVID-19 transmission.


Material and Methods
A literature review using PubMed, Cochrane Review, and Google Scholar database search was performed using the keyword terms “COVID-19”, “Coronavirus”, “Personal Protective Equipment” (PPE), “healthcare workers” (HCW), “protection”, “masks”, and “urology”. Non-English articles were excluded. We present a summary of key guidance provided by regulatory bodies as well as some of the key articles published to date relating to PPE.


Discussion
SARS-CoV-2 virus is found mainly in the respiratory system but is also in blood, feces, semen, and urine. Both standard infection control precautions (SICPs) and transmission-based precautions (TBPs) are nec-essary to reduce nosocomial transmission of COVID-19 infection. PPE includes gowns, gloves, masks or respirators, goggles, and face shields; however, wearing PPE is only part of many precautionary measures that are necessary to prevent viral transmission. When used appropriately PPE not only protects HCWs from patients but also protects patients from HCWs who may be asymptomatic carriers of COVID-19 infection. Attention should also be paid to fit testing and fit checking, donning and doffing, and ever-evolving guide-lines on PPE. Wearing PPE for a long time is also technically challenging and may adversely affect surgical outcomes. Shortages of PPE in the supply chain during the peak of the pandemic as well as concerns about substandard PPE should be considered for a possible second wave of COVID-19. Other key measures to minimize nosocomial SARS-CoV-2 virus transmission are a symptom and temperature screening of patients and staff; controlling the flow of patients, staff, and relatives in hospitals; self-isolation by patients before elective surgery; a robust testing protocol for both patients and staff; patient and staff cohorting; physical distancing; good hand hygiene; respiratory etiquette including face coverings for patients, staff and visitors; proper disposal of waste and enhanced cleaning; thorough cleaning and sterilization of surgical equipment performed post-operatively; choosing suitable anesthetic methods to minimize aerosolization of the virus; and if possible ensuring a negative-pressure theatre environment while dealing with COVID-19 positive patients. As scientific and regulatory bodies continue to issue updated guidance as more data is collected and a better knowledge base is developed regarding COVID-19 employers and staff need to keep up to date with guidance also.


Conclusion
COVID-19 will be around for the foreseeable future and infection rates may fluctuate as restrictions are eased. HCWs including urologists should take appropriate PPE measures not only in theatres, clinics, and endoscopy suits but also when performing simple tasks such as urine dipsticks, catheter, nephrostomy management, digital rectal examination (DRE), prostate biopsies, etc. as SARS-CoV-2 can be detected in feces, urine, and semen. Both employers and HCWs should adhere strictly to current guidelines and work together to minimize nosocomial transmission of COVID-19 infection.

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Article Details

How to Cite
Mukherjee, S., Bonatsos, V., & Raza, A. (2020). The Urologist, Personal Protective Equipment (PPE) and COVID-19 : A review of current challenges around the use of PPE as well as measures to reduce the risk of nosocomial COVID-19 transmission. Journal of Endoluminal Endourology, 3(4), e1-e14. https://doi.org/10.22374/jeleu.v3i4.104
Section
Original Article
Author Biographies

Subhabrata Mukherjee, Northwick Park Hospital, London North West University Healthcare NHS Trust, Harrow, UK

Department of Urology, Northwick Park Hospital, London North West University Healthcare NHS Trust, Harrow, UK

Vasileios Bonatsos, Northwick Park Hospital, London North West University Healthcare NHS Trust, Harrow, UK

Department of Urology, Northwick Park Hospital, London North West University Healthcare NHS Trust, Harrow, UK

Asif Raza, Northwick Park Hospital, London North West University Healthcare NHS Trust, Harrow, UK; Department of Medicine, Plymouth University Peninsula School of Medicine, Plymouth, England; Imperial College London, Medical School, London, United Kingdom.

Department of Urology, Northwick Park Hospital, London North West University Healthcare NHS Trust, Harrow, UK

References

1. World Health Organization. Coronavirus disease (COVID-19) pandemic. 2020. https://www.who.int/emergencies/diseases/novel-coronavirus-2019. Accessed September 29, 2020.
2. Fan C, Li K, Ding Y, et al. ACE2 Expression in Kidney and Testis May Cause Kidney and Testis Damage After 2019-nCoV Infection. medRxiv. 2020 Feb 13. doi:10. 1101/2020.02.12.20022418. https://www.medrxiv.org/content/10.1101/2020.02.12.20022418v1.
3. Zou X, Chen K, Zou J, et al. Single-cell RNA-seq data analysis on the receptor ACE2 expression reveals the potential risk of different human organs vulnerable to 2019-nCoV infection. Front Med. 2020;14(2):185–192. doi:10.1007/s11684-020-0754-0.
4. Kim JM, Kim HM, Lee EJ, et al. Detection and isolation of SARS-CoV-2 in serum, urine, and stool specimens of COVID-19 patients from the Republic of Korea. Osong Public Health Res Perspect 2020;11(3):112–117. doi:10.24171/j.phrp.2020.11.3.02.
5. Peng L, Liu J, Xu W, et al. SARS-CoV-2 can be detected in urine, blood, anal swabs, and oropharyngeal swabs specimens [published online ahead of print, 2020 Apr 24]. J Med Virol 2020;10.1002/jmv.25936. doi:10.1002/ jmv.25936.
6. Wang W, Xu Y, Gao R, et al. Detection of SARS-CoV-2 in different types of clinical specimens [published online ahead of print, 2020 Mar 11]. JAMA 2020;323(18):1843– 1844. doi:10.1001/jama.2020.3786.
7. Sun J, Zhu A, Li H, et al. Isolation of infectious SARS-CoV-2 from urine of a COVID-19 patient. Emerg Microbes Infect 2020;9(1):991–993. doi:10.1080/222 21751.2020.1760144.
8. Kashi AH, Fallah-karkan M, Amini E, Vaezjalali M. The presence of COVID-19 in urine: a systematic review and meta-analysis of the literature. medRxiv 2020 May 18. doi:10.1101/2020.05.15.20094920. https://www.medrxiv.org/content/10.1101/2020.05. 15.20094920v1.
9. Chen Y, Chen L, Deng Q, et al. The presence of SARS-CoV-2 RNA in the feces of COVID-19 patients. J Med Virol 2020;92(7):833–840. doi:10.1002/jmv.25825.
10. Amirian ES. Potential fecal transmission of SARS-CoV-2: Current evidence and implications for public health. Int J Infect Dis 2020;95:363-370. doi:10.1016/j. ijid.2020.04.057.
11. Zheng S, Fan J, Yu F, et al. Viral load dynamics and disease severity in patients infected with SARS-CoV-2 in Zhejiang province, China, January-March 2020: retrospective cohort study. BMJ 2020;369:m1443. Published 2020 Apr 21. doi:10.1136/bmj.m1443.
12. COVIDSurg Collaborative. Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study [published correction appears in Lancet. 2020 Jun 9]. Lancet. 2020;396(10243):27–38. doi:10.1016/ S0140-6736(20)31182-X.
13. NELA Project Team. Fifth patient report of the National Emergency Laparotomy Audit. 2019. https://www. nela.org.uk/downloads/The%20Fifth%20Patient%20 Report%20of%20the%20NELA%202019%20-%20Full%20Patient%20Report.pdf. Accessed September 3, 2020.
14. Kasivisvanathan V, Lindsay J, Rakhshani-moghadam S, et al. Evaluation of 30-day mortality for 500 patients undergoing non-emergency surgery in a COVID-19 cold site within a multicentre regional surgical network during the COVID-19 pandemic. medRxiv 2020 June 12. doi:10.1101/2020.06.10.20 115543. https://www.medrxiv.org/content/10.1101 /2020.06.10.20115543v1.
15. Evans S, Agnew E, Vynnycky E, Robotham JV. The impact of testing and infection prevention and control strategies on within-hospital transmission dynamics of COVID-19 in English hospitals. medRxiv 2020 May 20. Doi:10.1101/2020.05.12.20095562.
16. Treibel TA, Manisty C, Burton M, et al. COVID-19: PCR screening of asymptomatic healthcare workers at London hospital. Lancet 2020;395(10237):1608–1610. doi:10.1016/S0140-6736(20)31100-4.
17. Wu Z, McGoogan JM. Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) Outbreak in China: Summary of a report of 72 314 cases from the Chinese Center for Disease Control and Prevention [published online ahead of print, 2020 Feb 24]. JAMA 2020;10.1001/jama.2020.2648. doi:10.1001/ jama.2020.2648.
18. Health Education England. COVID-19 infection prevention and control guidance: standard infection prevention control precautions (SICPs) - all pathways. 2020. https://www.gov.uk/government/publications/wuhan-novel-coronavirus-infection-prevention-and-control/standard-infection-prevention-control-precautions-sicpsall-pathways. Accessed September 3, 2020.
19. Health Education England. COVID-19 infection prevention and control guidance: transmission based precautions (TBPs). 2020. https://www.gov.uk/government/ publications/wuhan-novel-coronavirus-infection-pre-vention-and-control/covid-19-infection-prevention-and-control-guidance-transmission-based-precautions-tbps. Accessed September 3, 2020.
20. Public Health England. COVID-19: Infection Prevention and Control (IPC). 2020. https://www.gov.uk/govern-ment/publications/wuhan-novel-coronavirus-infection-prevention-and-control. Accessed September 2, 2020.
21. Centers for Disease Control and Prevention. Coronavirus Disease 2019 (COVID-19). 2020. https://www.cdc.gov/coronavirus/2019-ncov/index.html. Accessed September 2, 2020.
22. Association for Perioperative Practice. COVID-19: Updated Infection Prevention and Control Guidance. 2020. https://www.afpp.org.uk/news/COVID-19_Up-dated_Infection_Prevention_and_Control_Guidance. 2020. Accessed September 3, 2020.
23. Centers for Disease Control and Prevention. Personal protective equipment: Questions and answers. Coronavirus disease 2019 (COVID-19). 2020. https://www. cdc.gov/coronavirus/2019-ncov/hcp/respirator-use-faq. html. Accessed September 3, 2020.
24. Howard BE. High-risk aerosol-generating procedures in COVID-19: Respiratory protective equipment considerations. Otolaryngol Head Neck Surg. 2020;163(1):98–103. doi:10.1177/0194599820927335.
25. Kim Y, Hale M. Pilot study to examine the use of a powered air purifying respirator (PAPR) in the operating room. Am J Infect Control 2017;45(6):S84. doi. org/10.1016/j.ajic.2017.04.124.
26. Howard RA, Lathrop GW, Powell N. Sterile field contamination from powered air-purifying respirators (PAPRs) versus contamination from surgical masks. Am J Infect Control 2020;48(2):153–156. doi:10.1016/j. ajic.2019.08.009.
27. Raza A. Letter to the Editor: SARS-CoV-2 in urine: Should endourologists be concerned and what personal protective equipment measures should be taken to protect the surgeon? J Endourol. 2020;34(6):709–710. doi:10.1089/end.2020.0476.
28. Royal College of Surgeons of England. COVID-19: Good Practice for Surgeons and Surgical Teams. 2020. https://www.rcseng.ac.uk/standards-and-research/ standards-and-guidance/good-practice-guides/corona-virus/. Accessed September 3, 2020.
29. Heffernan DS, Evans HL, Huston JM, et al. Surgical infection society guidance for operative and perioperative care of adult patients infected by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). Surg Infect (Larchmt) 2020;21(4):301–308. doi:10.1089/sur.2020.101.
30. Centers for Disease Control and Prevention. Appendix B. Air. Infection Control. 2003. https://www.cdc.gov/ infectioncontrol/guidelines/environmental/appendix/ air.html. Accessed September 3, 2020.
31. American Association of Gynecologic Laparoscopists. COVID-19: Joint Statement on Minimally Invasive Gynecologic Surgery. 2020. https://www.aagl.org/ news/covid-19-joint-statement-on-minimally-invasive-gynecologic-surgery/. Accessed September 2, 2020.
32. Forrester JD, Nassar AK, Maggio PM, Hawn MT. Precautions for operating room team members during the COVID-19 pandemic. J Am Coll Surg 2020;230(6):1098-1101. doi:10.1016/j.jamcollsurg.2020.03.030.
33. Public Health England. When to use a surgical face mask or FFP3 respirator. 2020. https://www.rdash.nhs. uk/wp-content/uploads/2017/08/Appendix-47-Surgical-Face-Mask-FFP3.pdf. Accessed September 3, 2020.
34. Steward JE, Kitley WR, Schmidt CM, Sundaram CP. Urologic surgery and COVID-19: How the pandemic is changing the way we operate. J Endourol 2020;34(5):541–549. doi:10.1089/end.2020.0342
35. American Society of Anesthesiologists. REVISED: The Use of Personal Protective Equipment by Anes-thesia Professionals during the COVID-19 Pandemic. 2020. https://www.asahq.org/about-asa/newsroom/ news-releases/2020/06/revised-the-use-of-personal-protective-equipment-by-anesthesia-professionals-during-the-covid-19-pandemic. Accessed September 3, 2020.
36. Health and Safety Executive. Fit testing face masks to avoid transmission during the coronavirus outbreak. 2020. https://www.hse.gov.uk/coronavirus/ppe-face-masks/ face-mask-ppe-rpe.htm. Accessed September 3, 2020.
37. Royal College of Nursing. Fit test versus fit check. 2020. https://www.rcn.org.uk/magazines/bulletin/2020/june/ fit-test-vs-fit-check-covid-19. Accessed September 3, 2020.
38. Chughtai AA, Chen X, Macintyre CR. Risk of self-contamination during doffing of personal protective equipment. Am J Infect Control 2018;46(12):1329–1334. doi:10.1016/j.ajic.2018.06.003.
39. Public Health England. COVID-19: personal protective equipment use for aerosol generating procedures. 2020. https://www.gov.uk/government/publications/ covid-19-personal-protective-equipment-use-for-aerosol-generating-procedures. Accessed September 3, 2020.
40. Liu Q, Luo D, Haase JE, et al. The experiences of health-care providers during the COVID-19 crisis in China: a qualitative study. Lancet Glob Health 2020;8(6):e790– e798. doi:10.1016/S2214-109X(20)30204-7.
41. Vidua RK, Chouksey VK, Bhargava DC, Kumar J. Problems arising from PPE when worn for long periods [published online ahead of print, 2020 Jul 20]. Med Leg J 2020;25817220935880. doi:10.1177/0025817220935880.
42. Rowan NJ, Laffey JG. Challenges and solutions for ad-dressing critical shortage of supply chain for personal and protective equipment (PPE) arising from coronavirus disease (COVID19) pandemic - Case study from the Republic of Ireland. Sci Total Environ 2020;725:138532. doi:10.1016/j.scitotenv.2020.138532.
43. Centers for Disease Control and Prevention. Optimizing Supply of PPE and Other Equipment during Shortages. Coronavirus disease 2019 (COVID-19). 2020. Accessed September 3, 2020.
44. Public Health England. Considerations for acute personal protective equipment (PPE) shortages. 2020. https://www.gov.uk/government/publications/wuhan-novel-coronavirus-infection-prevention-and-control/managing-shortages-in-personal-protective-equipment-ppe. Accessed September 3, 2020.
45. Health and Safety Executive. HSE safety alert issued against KN95 facemask. 2020. https://press.hse.gov.uk/2020/06/11/hse-safety-alert-issued-against-kn95-facemask/. Accessed September 3, 2020.
46. British Medical Association. COVID-19: refusing to treat where PPE is inadequate. 2020. https://www.bma.org.uk/advice-and-support/covid-19/ppe/covid-19-refusing-to-treat-where-ppe-is-inadequate. Accessed September 3, 2020.
47. Kratzel A, Todt D, V’kovski P, et al. Inactivation of severe acute respiratory syndrome coronavirus 2 by WHO-recommended hand rub formulations and alcohols. Emerg Infect Dis 2020;26(7):1592–1595. doi:10.3201/ eid2607.200915.
48. Todd EC, Michaels BS, Holah J, et al. Outbreaks where food workers have been implicated in the spread of foodborne disease. Part 10. Alcohol-based antiseptics for hand disinfection and a comparison of their effectiveness with soaps. J Food Prot 2010;73(11):2128–2140. doi:10.4315/0362-028x-73.11.2128.
49. Berardi A, Perinelli DR, Merchant HA, et al. Hand sanitisers amid CoViD-19: A critical review of alcohol-based products on the market and formulation approaches to respond to increasing demand. Int J Pharm 2020;584:119431. doi:10.1016/j.ijpharm.2020.119431.
50. Cowper A. What the law says about PPE responsibility. BMJ 2020;369:m1718. Published 2020 Apr 30. doi:10.1136/bmj.m1718.