PPE decontamination methods under scrutiny as shortage persists

Widespread shortages of personal protective equipment (PPE) for healthcare workers persist and are being exacerbated by continuing problems with global supplies.

Uncertainty, even for those front-line medical and nursing staff treating Covid-19 patients, has increased pressure on the HSE to urgently approve use of decontamination technology being rolled out in other countries.

Lack of a clear national policy on decontamination, especially on reusing face masks – normally disposed of after single use – has prompted some hospitals to seek their own solutions to ease pressures.

Nursing homes and other residential care facilities in particular have no certainty on PPE supplies beyond a few days. The amount supplied in some cases was 30 per cent of what was needed. In one instance, a hospital seeking to relocate a recovering Covid patient to a nursing home for “stepdown” purposes was told a place would be provided if a significant amount of PPE was supplied.

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The Irish Times is aware of instances where GPs were getting a handful of masks, rotating them by placing them in a bag and reusing them after the fifth day

There are also indications some healthcare staff have not been able to see patients because of a lack of face masks. Although this is not arising with treatment of Covid-19 patients in hospitals, some are borrowing face masks from other hospitals.

The Irish Times is aware of instances where GPs were getting a handful of masks, rotating them by placing them in a bag and reusing them after the fifth day, hoping that, were the virus present, it would by then be inactive.

Serious PPE shortages persist in many healthcare facilities, says public health nurse Mary Leahy, who founded not-for-profit Heroes Aid to raise funds to provide supports, including PPE and other resources, "to keep healthcare workers safe".

It received a donation of €1 million from MMA fighter Conor McGregor, much of which was used to send PPE – face masks, visors and gowns – to hospitals across the country. The charity, which emerged from a WhatsApp group of nurses highlighting PPE shortages, has separately raised €145,000.

“This is a global pandemic and we’re in a global market, which makes it difficult – it’s a seller’s market,” Leahy says.

Unsustainable situation

She strongly favours decontaminating PPE because the supply crisis “is costing us dearly”. Stressing she is not blaming the HSE and speaking in a personal capacity, she believes the current scenario is unsustainable. Vast amounts of PPE are worn only once and then disposed of – mostly to landfill.

The cost of weekly delivery of PPE “is conservatively estimated at approximately €9 million”, the HSE confirmed.

Globally, Leahy says, it is extremely challenging for every country as freight costs escalate. “We cannot allow [ourselves] to be ever exposed like this again.” If there is a second wave of coronavirus, she predicts it will cause devastation.

Heroes Aid continues to supply PPE on an emergency basis. “It’s a stop-gap approach when supplies are running short in between deliveries.”

She supports the use of Bioquell vaporised hydrogen peroxide (VH2O2) resteriliser, deployed in Canada and approved by the US Food and Drug Administration. It enables N95 and FFP2 medical masks to be reused up to 20 times without alteration. "They're higher-grade masks. They're expensive and like gold dust at the moment."

This will not eliminate the need to import masks but will reduce reliance on international supply chains. There is also a need to create an indigenous supply, to deploy decontamination and to make recyclable PPE to eliminate financial exposure.

Another WhatsApp group including up to 70 medics, virologists and medical device experts is trying to work on ways to resterilise PPE in the absence of a national policy.

Leahy understands the HSE at a high level is looking at how best to proceed.

She is aware of an Irish hospital that brought in a device to deal with hospital-acquired infections and is investigating its potential with PPE. “It’s about being innovative and creative and moving forward at a time of crisis.”

Desperate times

Cork-based respiratory consultant and former Irish Hospital Consultants Association vice-president Dr Oisín O’Connell says in normal circumstances a single-use approach would be deployed and the concept of PPE resterilisation would not be considered, which he would agree with.

“But if it means staff are short, which they 100 per cent are around the country, then it’s back to ‘perfection is the enemy of the good’. If there is an option to resterilise a mask to allow up to 20 uses using a vaporised hydrogen peroxide resteriliser, then I would be all for it, especially given FDA approval,” he adds.

He fears, however, the main desteriliser on the market will be bought up quickly by Canada, the US and the UK. "If not approved in Ireland soon, we are going to be at the back end of the queue."

Dr O’Connell says there is insufficient realisation of the scale of PPE needed in Ireland. “This is going to go on for 12 months minimum, and we will not be able to maintain supply lines for PPE, especially if one patient could easily require 15 masks a day.”

"Many of us on the front line would much rather a mask reprocessed with FDA-approved techniques rather than running out of masks or using a lower-standard mask"

Dr O’Connell says he is aware of anecdotal reports of hospitals running short of masks and “literally borrowing off each other; nursing homes bartering for them and HSE procurement community teams saying they are getting less than 30 per cent of their orders”.

A revised national strategy must take account of supply issues, usage patterns and implications of week-by-week Covid caseloads, underpinned by clarity on resource allocation and reuse of PPE, he believes.

“Many of us on the front line would much rather a mask reprocessed with FDA-approved techniques rather than running out of masks or using a lower-standard mask.”

Normally PPE is carefully removed and disposed of after each use, says Prof Neil Rowan, director of Athlone IT's Bioscience Research Institute. Due to its composition, it is extremely heat sensitive and not intended for reprocessing. However, the virus is responsive to sterilisation.

With professor of anaesthesia and intensive care medicine at NUI Galway John Laffey he is exploring decontamination solutions that reprocess PPE without destroying it. Their research is likely to inform any update to national policy.

Filling the gap

After validation to ensure safety and efficacy, reprocessing PPE using novel decontamination approaches is essential to protecting front-line workers and addressing shortages, he believes.

Success elsewhere in harnessing VH2O2 to decontaminate N95 masks means a similar authorised approach is likely to be deployed in Ireland, adds Rowan, an adjunct professor at NUIG school of medicine.

Their review of best evidence suggests VH2O2 and possibly UV irradiation within healthcare environments “can be used to fill this gap and will be paramount to ensuring the safety of healthcare workers”.

The HSE declined to comment on use of VH2O2 and Bioquell resterilisers

Ireland has been ahead of many countries in evaluating the best technology but Rowan accepts that delays in changing tack will lead to supply problems.

The HSE says it is aware of developments on decontamination and reuse of face masks and is exploring options to ensure continued supply of PPE. “However, at present decontamination of face masks for reuse is not practised.” It declined to comment on use of VH2O2 and Bioquell resterilisers.

Decontamination and reuse has been considered as an option in emergency situations where new masks are unavailable, but it is “not aware of any decontamination of faces masks for reuse occurring within the HSE to date”.

On PPE shortages, it says “the challenge Ireland faces in sourcing PPE in what is an exceptionally competitive and highly volatile global market is unprecedented”.

The major supply line established with China combined with increased domestic production of certain elements of PPE are essential to ensuring supply, the HSE adds. "Every effort is being taken to ensure available PPE is targeted at the areas of highest priority. Distribution of PPE continues on a daily basis right across the wider health service, including home care, residential and primary care services."