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March 19, 2020

Protecting Health Care Workers Against COVID-19—and Being Prepared for Future Pandemics

Author Affiliations
  • 1Center for Health Policy and Media Engagement, George Washington University School of Nursing, Washington, DC
  • 2University of Michigan School of Nursing, Ann Arbor
  • 3University of Michigan Rogel Cancer Center, Ann Arbor
JAMA Health Forum. 2020;1(3):e200353. doi:10.1001/jamahealthforum.2020.0353

As the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) spreads globally, signs are emerging that countries, including the United States, were woefully unprepared to protect health care personnel (HCP)—and thus, patients and the public. This lack of preparedness is shocking in light of the inevitability that a new global pandemic would emerge and the availability of guidance from the 2009-2010 H1N1 pandemic and the 2013-2016 Ebola outbreak.

Signs of Unpreparedness

On February 26, 2020, the New York Times reported that nurses and other female health care workers in Wuhan, China, were encouraged to shave their heads, ostensibly for hygienic purposes. State media referred to them as “the most beautiful warriors” in the war against SARS-CoV-2. A prior report noted that physicians, nurses, and other HCP had reused damaged masks. An estimated 3300 HCP were infected and 22 died in China because of “insufficient protective equipment.”

Now, hospitals across the United States are struggling to prepare for a potential onslaught of patients needing intensive respiratory care over prolonged periods. On February 29, the US Surgeon General Jerome Adams tweeted: “Seriously people- STOP BUYING MASKS! They are NOT effective in preventing general public from catching #Coronavirus, but if healthcare providers can’t get them to care for sick patients, it puts them and our communities at risk!” Over the past week, some nurses told us that N95 masks and hand sanitizers are being locked up to prevent pilfering of short supplies.

Nurses are also reporting that some hospitals are unprepared to provide them with the necessary personal protective equipment (PPE). On March 5, the union National Nurses United (NNU) reported that in a national survey of more than 6500 nurses, only 30% said that their health care organization had sufficient inventory of PPE for responding to a surge event (38% did not know), 63% said they had access to N95 respirators on their units, and 27% reported access to the more sophisticated and costly powered air-purifying respirators. Only 44% of the nurses said their employer had provided them with the necessary information about coronavirus disease 2019 (COVID-19) and how to respond.

Inadequate information about SARS-CoV-2 has fueled an uncertainty about the guidance from national authorities. On March 10, the US Centers for Disease Control and Prevention (CDC) issued “Interim Infection Prevention and Control Recommendations” that alarmed some health professionals. It recommended that face masks be used instead of N95 respirators, not because they adequately protect health care workers from the virus but because of a shortage of N95 respirators.

As Congress worked to pass the Families First CoronaVirus Response Act that President Trump has said he will sign, the American Hospital Association fought the legislation’s requirement that hospitals provide N95 respirators to staff caring for people suspected to have or who have been diagnosed with COVID-19. Nursing unions pushed back, noting that such a provision was needed to protect HCP and the patients under their care. The Strategic National Stockpile is said to have 13 million N95 respirators in stock and the federal government is expected to buy an additional 500 million. But a surge in cases could make even these numbers insufficient. Disagreement over the degree of required respiratory protection arises from sparse data on the airborne transmissibility of SARS-CoV-2.

Standards Without Enforcement

Although the Occupational Safety and Health Administration (OSHA) has standards for PPE and the CDC calls for hospitals to have respiratory protection programs, these standards are seldom enforced unless a state integrates them into health care facility inspections. For example, OSHA stipulates annual fit testing for HCPs for respirators—a practice that is evidence-based. We recently tweeted and talked with frontline nurses about their experiences with PPE. One nurse who is a fit tester on a medical-surgical unit said that in an effort to cut costs, her hospital reduced the number of designated staff who needed respiratory protection and required annual fit testing. In the NNU survey, 29% of the nurses responding said they had not received a fit test within the past year.

Health care workers should receive annual training on the use of PPE and additional education during surge events. Housekeeping staff often receive minimal training, and the NNU survey found that only 65% of the nurses responding said they had been trained, including in the donning and doffing of PPE.

As the information about SARS-CoV-2 changes, policies and practices may also change, and all HCP need to be aware of these changes. Among the nurses we communicated with, those who received frequent, evidence-based information from hospital leadership expressed less anxiety about the pandemic. Concerns about one’s own health and the health of one’s family demand accurate, timely, and frequent communication from hospital leaders and infectious disease experts. Two nurses on Twitter who have public health credentials and have participated in daily high-level meetings on SARS-CoV-2 expressed their frustration with hospital leaders who have made decisions without conferring with public health experts.

Standards and recommendations that are seldom enforced by the government demand an enlightened hospital leadership. One nurse executive at a leading New York City hospital noted that administrators must ensure that their staff feel safe, respected, prepared, and supported.

Being Prepared

Will we be better prepared for the next pandemic that may be even deadlier and more difficult to contain than SARS-CoV-2? We recommend the following:

  1. Federal, state, and local governments must reinvest in a robust public health system and rely on that system for accurate and timely information and communications with the public, along with other emergency responses to potential pandemics. Guidance to the health care sector and to society should be evidence-based, consistent, and aligned with local decision-making.

  2. The federal government should ensure that the nation’s health care sector has an adequate supply of PPE, including more reusable respirators. Health care facilities are major contributors to environmental waste. Problems with the supply of N95 respirators suggest that reliance on disposable respirators threatens our preparedness during surges. The National Academies of Science, Engineering, and Medicine (NASEM) published a consensus report last year on “Reusable Elastomeric Respirators in Health Care: Considerations for Routine and Surge Use” that calls for greater use of reusable elastomeric respirators that have important advantages but would require strict protocols for storage, cleaning, and disinfection.

  3. Develop onshore capacity for rapid PPE production during surges. Rationing PPE is unacceptable. Problems with the PPE supply chain were evident during the H1N1 pandemic. Most PPE is produced offshore, particularly in China. Having manufacturing capabilities within the United States increases the likelihood of a stable PPE supply.

  4. Under the Biomedical Advanced Research and Development Authority (BARDA), incentivize public-private partnerships to develop novel PPE that is cost-effective, safe, and comfortable. BARDA was authorized under the Pandemic and All-Hazards Preparedness Act of 2006 and was recently reauthorized in 2019 but has not been sufficiently proactive in providing funding and technical assistance to develop new products for use during a public health emergency. Innovative approaches to train health care workers on PPE use should be included.

  5. Health system leaders should be required to demonstrate competency in basic principles of public health and emergency preparedness, including effective crisis communications. The American College of Healthcare Executives calls on hospital executives to “actively participate in disaster planning and preparedness activities” in ways that mitigate risk to the organization. But how do hospital leaders demonstrate that they are competent in public health principles and emergency preparedness? Academic programs should strengthen disaster preparedness content in their degree programs and offer robust continuing education on this topic. Health care executives face notable pressures to streamline, redesign, and respond to the dynamic regulatory and payment environment. Disaster preparedness can be left in the background. But ensuring that the leadership team has credible expertise in disaster preparedness and excellent crisis communications should be the minimum expectation.

The NASEM report and other reports that detail lessons learned from prior public health emergencies provide us with clear direction on how to be more prepared for the next pandemic, including how best to protect the people who will be caring for those who are seriously ill. Let us add the lessons we are learning from our experience with COVID-19 and act before the next pandemic arises.

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Article Information

Open Access: This is an open access article distributed under the terms of the CC-BY License.

Corresponding Author: Diana J. Mason, PhD, RN, Center for Health Policy and Media Engagement, George Washington University School of Nursing, 1919 Pennsylvania Ave NW, Ste 500, Washington, DC 20006 (djmasonrn@gmail.com).

Conflict of Interest Disclosures: Dr Friese reported serving as a volunteer member of the 2018 National Academies of Science, Engineering, and Medicine (NASEM) ad hoc consensus committee entitled Study of the Use of Elastomeric Respirators in Health Care and his travel to committee meetings was paid by the NASEM. No other disclosures were reported.

Disclaimer: This work solely reflects the view of the authors and does not reflect the views of the NASEM or its affiliates.

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    1 Comment for this article
    Emerging evidence describing gastrointestinal manifestations of SARS-CoV2 elevates concern for possible bio-aerosol transmission
    Carmen Mcdermott, MD | Providence Sacred Heart Medical Center Spokane and Spokane Teaching Health Center Spokane
    Thank you Drs. Mason and Friese for your article.

    I also want to comment that given the novelty of SARS-CoV2, the medical community has limited evidence and understanding about the transmission mechanisms for SARS-CoV-2. We certainly do not know enough about SARS-CoV-2 to conclusively say whether bio-aerosol transmission is a mechanism of transmission or not, as discussed in an article by bio-aerosol expert, Dr. Lisa Brosseau (1). New evidence describes gastrointestinal manifestations in up to 33% of patients with SARS-CoV-2, fecal shedding in potentially 50% of patients, evidence of concern for transmission of the illness
    from patients with gastrointestinal symptoms to health care workers in a hospital setting (2-6). Experts are raising concern for fecal transmission and the potential for infectious aerosols which have been shown to be produced by toilet flushing (6-9). If this is a mode of transmission for this pathogen, important implications for infection control and PPE in the health care setting as well as the community exist. Furthermore, considerations should be given to solutions for mitigating this mode of transmission in the hospital setting: using lids, having patients use non-flushing commodes, modifying ventilation, and using air filtration systems. Increased public messaging about the potential for gastrointestinal manifestations is important as well. Clearly more research is needed to clarify this issue, yet in this time of urgent need to reduce transmission, we should be having ongoing discussions, engaging experts, and expediting research into the potential for close and long range aerosol transmission and the concern for bio-aerosols when patients have gastrointestinal manifestations.

    Carmen McDermott MD FACP
    Faculty, Internal Medicine Residency, Providence Sacred Heart and Spokane Teaching Health Center
    Clinical Instructor, University of Washington School of Medicine

    1. Dr. Lisa Brosseau. Bioaerosol expert: http://www.cidrap.umn.edu/news-perspective/2020/03/commentary-covid-19-transmission-messages-should-hinge-science
    2. Dr. David Johnson commentary: https://www.medscape.com/viewarticle/926856?src=mkm_ret_200322_mscpmrk_gastroenterology_covid&uac=315924MJ&impID=2318549&faf=1
    3. Gu J, Han B, Wang J. COVID-19: Gastrointestinal manifestations and potential fecal-oral transmission. Gastroenterology. 2020 Mar 3. pii: S0016-5085(20)30281-X. [Epub ahead of print] https://doi.org/10.1053/j.gastro.2020.02.054
    4. Xiao F, Tang M, et al. Evidence for gastrointestinal infection of SARS-CoV-Gastroenterology. 2020 Mar 3. pii: S0016-5085(20)30282-1. [Epub ahead of print] https://doi.org/10.1053/j.gastro.2020.02.055
    5. Luo S, Zhang X, Xu H, Don't overlook digestive symptoms in patients with 2019 novel coronavirus disease (COVID-19), Clinical Gastroenterology and Hepatology (2020), doi: https://doi.org/10.1016/j.cgh.2020.03.043.
    6. Liang W, Feng Z, Rao S, et al Diarrhoea may be underestimated: a missing link in 2019 novel coronavirus. Gut Published Online First: 26 February 2020. doi: 10.1136/gutjnl-2020-320832
    7. Knowlton, Samantha D et al. “Bioaerosol concentrations generated from toilet flushing in a hospital-based patient care setting.” Antimicrobial resistance and infection control vol. 7 16. 26 Jan. 2018, doi:10.1186/s13756-018-0301-9
    8. Johnson, David et al. “Aerosol Generation by Modern Flush Toilets.” Aerosol science and technology : the journal of the American Association for Aerosol Research vol. 47,9 (2013): 1047-1057.
    9. Johnson, David L et al. “Lifting the lid on toilet plume aerosol: a lite