Cross-sectional study of personal protective equipment use, training and biosafety preparedness among healthcare workers during the first months of the SARS-CoV-2 pandemic in Brazil

Introduction

The WHO declared COVID-19 a pandemic on 11 March 2020. Until 10 March 2023, Brazil accounted for more than 37 million cases and 699 276 deaths, occupying the third position in the number of cases and second in number of deaths globally.1 During the first year of the pandemic, vaccines were unavailable. Many healthcare workers (HCWs) were infected, and it is estimated that between 80 000 and 180 000 HCWs died worldwide between January 2020 and May 2021.2 Brazil has more than 5 million registered HCWs.3 By September 2021, 568 358 cases of SARS (Severe acute respiratory syndrome) were reported, and COVID-19 was the cause of 95% of HCWs’ hospitalisations for SARS that led to death.4 Data on the actual number of deaths due to COVID-19 in Brazilian HCWs are fragmented and inaccurate. The WHO estimates that the country accounts for the second largest death toll of HCWs due to COVID-19, with 9769 HCWs deaths from January 2020 to May 2021.2 In contrast, a survey from the Brazilian National Registry indicates 24.5% excess deaths in HCWs from March 2020 to February 2021 compared with the same period of 2019 (from 3571 to 4446 deaths), with 1411 deaths registered due to COVID-19.5 Noteworthy, Brazil also reports one of the highest absolute numbers of HCWs with tuberculosis, another airborne disease. Around 1000 cases are reported annually, behind China and India only.6 7

Increased risk of SARS-CoV-2 infection by HCWs has been associated with personal protective equipment (PPE) availability, workplace conditions, profession, contact with COVID-19 patients and the availability of diagnostic tests.8 HCWs are at high risk of infection due to prolonged exposure and intimate contact with SARS-CoV-2 infected patients, particularly during invasive procedures with aerosol formation.9 To protect HCWs from biological hazards in the workplace, a hierarchy hazard control system through collective and individual biosecurity measures is usually adopted. This system ensures collective protection, such as risk elimination and replacement, followed by engineering and administrative measures and the correct use of PPE.10 Although PPE is the last biosecurity measure, it is an indispensable tool to protect HCWs from infection.10

When the SARS-CoV-2 emerged, HCWs changed their everyday measures to ensure protection from respiratory and contact transmission of the virus, mainly using PPE. The scarcity of PPE that ensued worldwide and in Brazil11 12 put into evidence the lack of preparedness to fight a respiratory pandemic. Aware of the risks that the SARS-CoV-2 pandemic posed to the HCWs in Brazil, in April 2020, biosafety experts from the University of São Paulo created a website (EPISaúde, www.episaude.org) to provide free information on how to properly use and discard PPE in the context of COVID-19 transmission. Here, we report the results of a survey with HCWs conducted through this platform from 24 April 2020 to 14 July 2020. Our objective was to evaluate the HCWs’ perception of PPE use, preparedness and training in the early months of the SARS-CoV-2 pandemic in Brazil. We also report for the first time a speech content analysis of statements provided by Brazilian HCWs at the time of the survey.

Methods

Results

Comparison between HCWs TCOVID-19 and HCWs NTCOVID-19

Professional characteristics

About half of the HCWs (812/1410; 57.6%) reported they were attending/taking care of confirmed and/or suspected COVID-19 patients (HCWs TCOVID-19) at the time of the survey (table 1). Being from TCOVID-19 or NTCOVID-19 groups was statistically associated with the profession, job sector, workplace and years of work experience (table 1). Overall, the most frequent profile of the HCW TCOVID-19 at the time of the survey was of nurses, nurse technicians and physicians working in hospitals and UBS/UPA/AMA and having less than 20 years of work experience. In addition, the proportion of HCWs working in the public sector was higher in the TCOVID-19 group (64.4% than in the NTCOVID-19 group (49.3%), while the proportion of HCWs working in the private sector was higher in the NTCOVID-19 group (32.6%) than in the TCOVID-19 group (17.7%).

PPE access and reuse

Being from TCOVID-19 or NTCOVID-19 groups was statistically associated with access to PPE before and during the pandemic, the use of PPE during the pandemic, the reuse of disposable PPE before and during the pandemic and reuse of N95 respirators during the pandemic (table 1). Although more than 95% of the HCWs had access to PPE in their workplace before and during the pandemic, the proportions of HCWs with access to PPE in both periods were higher in the TCOVID-19 group (96.9% and 99.1%, respectively) than in the NTCOVID-19 group (94.1% and 95.2%, respectively) (table 1). This association being significant before and during the pandemic suggests that access is influenced by profession, as professional composition of the groups is different. The proportions of HCWs reporting access to PPE were different depending on the PPE type and, except for gloves, were higher at the time of the survey than before the pandemic for both groups, with the highest differences seen with the N95 respirators and face shields (online supplemental figure S1A,S1B).

Reuse of disposable PPE was identified as common practice before and during the pandemic (table 1). Nevertheless, the proportion of HCWs reusing disposable PPE increased from about 50% before the pandemic to 63% at the time of the survey (table 1). This increase was led by HCWs TCOVID-19, as the proportion of HCWs reusing disposable PPE during the pandemic (70.1%) was higher in the TCOVID-1 group compared with the NTCOVID-19 group (52.5%) (table 1). HCWs TCOVID-19 reported an increase in the reuse of all PPE at the time of the survey compared with before, except for gloves and face shields (online supplemental figure S1C).

As with other PPE, the reuse of N95 respirators was common practice before the pandemic (table 1). Among those using N95 respirators (disposable or reusable, plastic types) before the pandemic (n=707), 57.6% were reusing the disposable N95 respirator. During the pandemic, this proportion of HCWs reusing disposable N95 respirators increased to 75.8% (table 1). The proportion of HCWs reusing the disposable N95 respirators during the pandemic was significantly higher in the TCOVID-19 group compared with the NTCOVID-19 group, alarmingly reaching 80% of this population (table 1).

Training for the use, maintenance and disposal of PPE and N95 respirator fit test

About half of the HCWs (57%) reported receiving training to use, maintain and dispose of PPE (table 1). The proportion of HCWs who received training (59.4%) was higher in the TCOVID-19 group than in the NTCOVID-19 group (53.2%). Among the HCWs who had training, most received training only once or twice over the past 5 years (HCWs TCOVID: 301/812, 37.1%; HCWs NTCOVID: 192/598, 32.1%) (figure 1A). The top source of training was their current workplace institution, followed by self-taught training (figure 1B).

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Figure 1

Training on PPE use, maintenance and disposal; N95 respirator fit tests; type of respiratory protection at the workplace and ranked responses of HCWs. (A) Frequency of training on PPE use, maintenance and disposal by HCWs over the past 5 years. (B) Place of training on PPE use, maintenance and disposal by HCWs. (C) Frequency of N95 respirator fit tests by HCWs over the past 5 years. (D) Type of respiratory protection used by HCWs in the workplace at the time of the survey. (E) Perceived stress level of HCWs during the pandemic (on a scale of 0, no stress, to 10, a lot of stress). (F) Perceived safety level reported by HCWs regarding SARS-CoV-2 infection risk in their workplace during the pandemic (on a scale of 0, not safe, to 10, very safe). (G) Perceived impact of lack of training regarding the use of PPE on the risk of infection by HCWs in the workplace (on a scale of 0, no impact, to 10, a lot of impact). (H) Perceived impact of the lack of PPE on the risk of infection by HCWs in the workplace (on a scale of 0, no impact, to 10, a lot of impact). (I) Perceived impact of PPE cost on the risk of infection by HCWs in the workplace (on a scale of 0, no impact, to 10, a lot of impact). *p=0.033535, ****p=0.000013. A total of 1410 HCWs responded to the questionnaire from 24 April 2020 to 14 July 2020. HCWs, healthcare workers; NS, not significant; NTCOVD-19, not TCOVID-19; PPE, personal protective equipment; TCOVID-19, treating COVID-19 patients.

Surprisingly, the vast majority of HCWs (85.2%) did not have an N95 respirator fit test performed over the past 5 years (table 1; figure 1C). Although short of desirable, the proportion of HCWs who had an N95 respirator fit test done (16.3%) was higher in the TCOVID-19 group compared with the NTCOVID-19 group (7.9%) (table 1). Considering HCWs TCOVID-19 that reported using the N95 respirator as respiratory protection in the workplace (n=641), 81.3% (521/641) never performed an N95 respirator fit test over the past 5 years.

Respiratory protection used by HCWs at the workplace during the pandemic

HCWs were asked the types of respiratory PPE they were using at the workplace during the pandemic. Surgical masks were the main respiratory protection used by HCWs at their workplace (HCWs TCOVID: 629/812, 77.4%; HCWs NTCOVID: 442/598, 73.9%; figure 1D). The proportion of HCWs TCOVID-19 using N95 respirators (563/812, 69.3%) was higher than HCWs NTCOVID-19 (281/598, 47%; figure 1D). Remarkably, 13% (106/812) of the HCWs TCOVID-19 and 22.1% (132/598) of the HCWs NTCOVID-19 still reported using homemade masks in their workplace at the time of the survey (figure 1D).

Ranked responses

HCWs TCOVID-19 reported statistically higher levels of stress during the pandemic and feeling less safe in their workplace regarding the risk of SARS-CoV-2 infection than HCWs NTCOVID-19 (figure 1E,F). Both HCWs TCOVID-19 and NTCOVID-19 perceived high impact levels (level>8) of the lack of PPE or training on PPE use, and PPE cost on their infection risk at the workplace (figure 1G–I).

Discussion

Results show that many HCWs and healthcare institutions in Brazil were not prepared to handle the biosafety risks of a respiratory pandemic. Because of the time of the survey (most questionnaires were sent by the beginning of May 2020), many healthcare facilities were still evaluating how to provide PPE and modify workflows; thus, current findings do not reflect the months that followed nor the current state of the pandemic. Yet, they represent a historical moment of the early months of the SARS-CoV-2 pandemic in Brazil and can be used for planning and contingency strategies for future pandemics. Overall, this study corroborates with surveys showing that HCWs from Latin America suffered from a lack of governmental support, biosafety and related policies in their workplace.16 To our knowledge, this is also the first study to incorporate inductive content analysis of Brazilian HCWs statements in the context of the SARS-CoV-2 pandemic.

Dentists, comprising a large proportion of the surveyed population, are highly exposed to patients that may be unaware of a SARS-CoV-2 infection. Speech analysis showed their worrying need for information on how to adapt practices to increase their personal protection while working. Cross-sectional studies on dentists conducted early in the pandemic revealed significant impacts, including lack of specific training for patient interaction,17 substantial reduction in workload18 19 and recommendations to delay elective procedures to prioritise urgent care and conserve PPE supplies.20 Our findings align with these, possibly explaining why most dentists did not treat patients suspected or positive for COVID-19. In the following months, the Brazilian Dental Health Council issued guidelines for the biosafety of dentists.21 The absence of such guidelines prior to the pandemic underscores unpreparedness for a respiratory viral pandemic in this healthcare sector, even though dentists are well accustomed to the use of PPE.

The proportion of most experienced HCWs (>21 years of experience) was higher in the group NTCOVID-19 compared with the group TCOVID-19. There may be three possible explanations for this finding. First, less experienced HCWs may lack training on PPE use, being inclined to access the EPISaúde website, biasing the results. Second, it is possible that less experienced HCWs were able to endure the more intense workloads associated with the front-line response than more senior HCWs. And third, older HCWs refrained from working with COVID-19 patients because they were at increased risk of severe disease and death by SARS-CoV-2.

A positive outcome of this study is that access to PPE increased during the pandemic. A significant increase was seen for N95 respirators and face shields, which means this was probably the first time certain HCWs were using these PPE. Considering that almost half of the respondents had never had PPE training, there were great chances that N95 respirators and the face shields were not being used correctly. The correct fit of N95 respirators guarantees efficient airborne protection, and the lack of training regarding their use by HCWs correlates with poor respirator fit.22 23 Unfortunately, more than 80% of the surveyed respondents had never performed an N95 respirator fit test over the past 5 years. The N95 respirator fit test was also not mentioned in HCWs’ statements, which suggests a lack of knowledge about the test, especially considering that this topic was addressed in similar qualitative analyses from other countries.24 A study in an Australian tertiary institution showed that without a fit test, more than half of HCWs were using an N95 respirator that did not provide adequate airborne protection.25 The Brazilian Health Agency (ANVISA) recommends annual fit tests and tests on changes in face shape or respirator models.26 Thus, it should be investigated why the recommendations were not being followed by many healthcare institutions, because this may have contributed to the Brazilian HCWs’ infection rate by SARS-CoV-2. Since the N95 respirator fit test and the PPE training are complementary and should take place regularly, it could be beneficial to execute them simultaneously, as they are necessary to ensure the safety of HCWs dealing with airborne pathogens in healthcare settings.

More than half of the HCWs using respiratory protection of N95-type were reusing disposable N95 respirators before the pandemic, and the percentage increased to around 80% during the pandemic, suggesting that this is a chronic issue in the Brazilian healthcare system. These HCWs righteously voiced their concerns about the reuse of N95 respirators in their statements. They also mentioned that the reuse of the same disposable N95 respirator was prolonged, ranging from 7 to 30 days. Brazil is a high tuberculosis burden country and the third country in the world with the greatest number of reported tuberculosis cases among HCWs,6 7 another important airborne disease. No study to date has been conducted to identify risk factors associated with the high TB burden among HCWs in Brazil. Results from this study emphasise the need to evaluate practices involving respiratory protection to prevent TB transmission. Lack of adequate infection control training, reuse of N95 respirator and inappropriate N95 respirator sealing and PPE handling have been identified as risk factors for infection of HCWs with other airborne pathogens worldwide, such as SARS-CoV-1.27–30

It is inherently difficult to attribute infection specifically and only to the reuse of N95 respirators in HCWs. This practice is often accompanied by other poor infection control measures and high community transmission of the related pathogen, which can be confounding factors. In a randomised trial with 12 HCWs, the reuse of N95 respirators previously contaminated with the benign bacteriophage MS2 led to virus transfer to the face, hands and clothing of the HCWs, suggesting potential routes of transmission and infection if the respirator is reused.31 In addition, the prolonged use of N95 respirators may cause PPE to malfunction.32 While recommendations for extended use or limited reuse of respiratory protection in response to PPE shortages have been made during previous public health emergencies, these practices should not become routine. It is shocking that the reuse of disposable, single-use N95 respirators was common practice among the respondents of this study even before the pandemic, that N95 respirator fit tests were almost absent and that PPE training was deficient.

The lack of PPE that ensued in the early months of the pandemic in Brazil could have been at least partially prevented or less severe if the use of N95 respirators had been widespread and performed correctly before the pandemic. Hospitals would have a robust stock, and the national industry would perhaps be more developed to produce this type of PPE and less dependable on external sources. Globally, the lack of PPE led to rationing recommendations, extended use and reuse when necessary.33 At the time of the survey (April–July 2020), the N95 respirator was being indicated only during medical procedures predisposing to aerosol formation, which could explain why some HCWs TCOVID-19 did not have access to this PPE. Nevertheless, many HCWs expressed frustration about wearing the surgical mask instead of the N95 respirator. As shown in other studies conducted in Latin America,34 not all HCWs TCOVID-19 had access to N95 respirators and reported their absence.

Most HCWs from this survey considered the lack of training as a high-impact factor for HCWs’ infection risk at the workplace, extensively addressed this in their statements. Protocol deviations and self-contamination during PPE donning and doffing have been reported, emphasising the need for regular PPE training, as practice can reduce protocol deviations and, consequently, the risk of HCW infection.35–38 The COVID-19 pandemic created just-in-time training opportunities for HCWs, with many organisations developing training resources. However, a study showed that most of these resources did not address the knowledge necessary to effectively implement infection control measures.39 COVID-19-associated training should not replace the need for formal training provided by universities, governmental agencies or healthcare facilities. It is also necessary to ensure that training is based on risk assessments and covers the needs of HCWs working in that specific setting.

The lack of information regarding the disease and PPE needs for specific procedures can lead to PPE misuse, lack of PPE and distorted perception of absence.34 At the time of the survey, there were no clear recommendations on specific PPE use for handling COVID-19 patients. However, recommendations were available for other airborne transmission pathogens, such as SARS-CoV-1, H1N1 and tuberculosis.40 41 Most HCWs surveyed worked in the public sector. More than 70% of the Brazilian population depends on SUS, which is public. The SUS has been suffering from a lack of funding and resources for years, which interferes with PPE, equipment acquisition12 and workforce. The lack of funding and work overload may help explain the lack of training for HCWs working in public institutions.

Conclusion

Many HCWs and healthcare institutions were unprepared to face the SARS-CoV-2 pandemic. This happened in spite of (1) a previous Brazilian Preparedness Guideline for Influenza,41 (2) SARS-CoV-2 reaching other countries before Brazil and (3) Brazil being a high burden country for other significant airborne diseases, such as tuberculosis. The way healthcare settings dealt with equipment and PPE acquisition, the high demand, problems in the international supply chain of PPE, and governmental failures to address these problems are some of the reasons leading to PPE shortage42 in the first semester of 2020, particularly of N95 respirators. However, our study shows that the lack of training, the negligible N95 respirator fit tests and PPE reuse are not exclusively related to the COVID-19 pandemic, yet a chronic problem of the Brazilian healthcare system.

To change this scenario and better handle future pandemics, structural, educational and behavioural changes are required in the Brazilian healthcare system and its professionals. Biosafety training should be mandatory in healthcare-related undergraduate and graduate courses and institutions, and continued education should be enforced. In addition to elaborating biosafety guidelines for specific pathogens and biosafety hazards, it is necessary to invest in teaching and training. It is also necessary to invest in and develop the national industry of PPE, to decrease the dependency on international sources, which could also be based on higher demand by decreasing PPE reuse. Furthermore, clear guidelines for training, the rational use of PPE, PPE stock management, risk assessment, and collective and individual biosecurity measures should be developed and implemented in the SUS. These measures must become a reality now and should not wait until the next pandemic emerges; otherwise, we will face the same problems, and more lives will be lost.