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Original illustration for Healthcare-Arena by Fran Orford

The emergence of Covid-19 has led to unprecedented levels of ICU occupancy and mechanical ventilator use in the UK and worldwide. With non-intensivists often redeployed into ICUs to meet the staffing shortfall, they may be unfamiliar with the eye care of critically ill patients. Prone positioning (facing downward) has been used to improve ventilation of Covid-19 patients with acute respiratory distress syndrome (ARDS), and this has its own implications for eye health and care. Mr. Ian Murdoch, a former NHS consultant ophthalmologist, recently responded to the call for retired clinicians to return to assist in the COVID-19 emergency. Acting as a member of the proning team for ventilated patients at the NHS London Nightingale Hospital, he used his invaluable experience as an ophthalmologist to develop standard operating procedures (SOPs) for the eye care of these patients and to deliver training on this topic to his new colleagues. I interviewed him about his experience, and the ophthalmic advice he has for those caring for prone patients.

Q. What was your role as part of the proning team?
A. We were called to the patients on the ward whenever the team caring for them had prescribed prone ventilation. Once prone, patients required regular head turns, and were generally de-proned after 18 hours. This cycle was then repeated as demanded by their clinical condition.

Q. What are the main implications of prone positioning for eye health and eye care?
A. There are three principal implications. Firstly, the prone position means direct pressure could be put on the eye. This can increase intraocular pressure and occlude the central retinal artery, leading to complete sight loss. This is well recognised where patients are anaesthetised prone, such as during spinal surgery, hence it is routinely checked for. Secondly, exposure of the eyes when the lids are inadequately closed can lead to exposure keratopathy (drying out of the cornea) and the cornea being subjected to trauma. Thirdly, dependent oedema can lead to swollen lids and chemosis. This may prevent visualisation of the eye, impair eye closure, and in some instances cause entropion. Proning-related periocular swelling has also been implicated in the development of posterior ischaemic optic neuropathy (PION) causing profound vision loss.

Q. What was your experience of the eye care received by prone patients at the Nightingale?
A. In such a busy environment, where the life and death issues of ventilation, blood pressure control and central/arterial line management are so important, non-life threatening matters such as catheter care, oral care and eye care come lower down the list of priorities for good reason. However, I did find quite marked lid oedema in some patients, and this was not being addressed.

Q. What changes did you make after reviewing the patients?
A. We introduced a more systematic regimen to the eye care to address the three implications outlined above:

  1. Pressure on the eye/orbits was routinely checked for and no further intervention was required.
  2. Exposure was prevented by obtaining EyeGard – an adhesive dressing simply applied to the eyes to hold the lids closed and protect them. Lubricant ointment was applied prior to the use to the guard and the guards used routinely in any patient with no protective corneal reflex.
  3. Dependent oedema was treated by applying lubricating ointment to the eye, followed by Jelonet and then double eye pads.

SOPs were produced together with training material in order to add this simple eye care regimen into the routine ward practice.

Q. Finally, what is your take home message to medical staff in ICU for eye care of prone patients?
A. Whilst eye-care should not be the main thought whilst attending the critically ill, the simple steps outlined above can prevent most injuries and enormously aid patient recovery. As patients wake up their eyes are not swollen, painful or blurred, and avoidable complications such as corneal abrasions or infections do not have to be treated.

 

If you would like to comment on any of the issues raised by this article, particularly from your own experience or insight, Healthcare-Arena would welcome your views.

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Blind Onchocerciasis sufferer being led
A remarkable success story in the making

I find many things slightly odd in reactions to health progress. Whilst whizzy new diagnostic and therapeutic avenues get major press, preventive measures get surprisingly little money and press and yet are far more effective and preferable. Similarly, major advances in diseases affecting the poor can often be overlooked. Onchocerciasis or river blindness is one such disease. Table 1 shows the causes of global blindness as listed in 1993, onchocerciasis is up there with the leaders.

Cause Number of blind in millions
Cataract 14.0-17.0
Trachoma 2.0-6.0
Glaucoma 3.0-5.0
Xerophthalmia 0.5-1.0
Onchocerciasis 0.5-1.0
Age-related macular degeneration 1.0-2.0
Diabetic retinopathy 1.0-2.0
Leprosy 0.3-0.5
Others 3.0-5.0

Table 1: 1993 estimates of causes of worldwide blindness taken from Blindness in the World Survey of Ophthalmology November 2000 Volume 45, Supplement 1, Pages S21–S31

When one considers that it almost uniquely affects very poor communities in equatorial Africa and Latin America the numbers become even more impressive. Back in 1989-1992 I was working in communities with onchocerciasis, two things were striking. Firstly up to 1 in 10 individuals were blind meaning (given the age structure of many more children than adults) it was almost an expectation that you would be blind by the age of 40. Secondly most of the local doctors I was working with had never seen a case before we went to the rural communities we were working in simply because the people could never afford to travel the distance into town to be examined.

What if I now tell you that we are on the path to eradicating this dreadful disease from the planet?! A success story surely worthy of knowing about and celebrating?

OK what is it?

River blindness is caused by a worm that gets into the body as a result of a small black Simulium fly biting you. The fly’s larvae develop in fast flowing water hence the fly is found by rivers with overhanging vegetation (for the larvae to cling to) and turbulence in the flow (which increases oxygen in the water). Good farmland is by rivers and the poor can’t afford to pick and choose their location hence live there in order to scratch out a livelihood.

Both male and female adult worms live inside infected hosts and produce millions of microfilariae (babies) which are the things that cause most trouble. They cause severe itching disturbing sleep, skin disease giving social stigma and eye disease leading to blindness.

What has been done to try to help prevent it?

For years drugs against the worm were pretty crude and could cause as much harm as the disease they were treating. A huge project was therefore set up to try to prevent the fly from breeding and infecting people. This was pretty effective but very expensive to maintain and as soon as the river larviciding was stopped there was a risk of recurrence since the flies can travel of 100 miles using air currents and soon reinvade.

A therapeutic breakthrough

The drug ivermectin (Mectizan) was developed as a deworming agent for veterinary medicine. In 1982 Aziz thought tried it in humans and we have never looked back since. A huge advantage is that you only need to take the drug once a year. I was part of a large trial that proved you could give the drug to entire communities with infection in them rather than testing individuals for infection before treating.

How to get the drug to those that need it

Having proven the drug was safe there were challenges to widespread distribution. A remarkable step forward by the company making the drug sorted this out. In 1987 the Mectizan Donation Programme was established. Merck Sharp and Dhome make the drug 24/7 throughout the year for veterinary use. They now turn the factory over for one or two days to human production and donate that for free. The advantages for the firm are great publicity, tax breaks and the fact they are unlikely to make large profit from countries who can ill afford money to pay for drugs for the poorest in their midst. The advantages to humanity are untold, to name but a few.

  • The distribution and oversight has to be funded and guaranteed by local organisations/initiatives with clear feedback. This makes the drug one of the best monitored and supervised on the planet.
  • Novel methods of drug delivery have been pioneered. Since many situations have no primary health care structure a method of delivery was devised where local communities identified who they wanted to distribute the drug (a teacher, a head of village, a priest/Imam etc). This person then received, distributed and checked/reported side effects. The name given to this is Community Directed Treatment with Ivermectin.
  • Checking dose was tricky since scales are in short supply and often break. A study was done showing use of height a very good proxy and much more practical
The success to date

With massive support from many charities, Ministries of Health and local organisations over 250 million individuals were receiving annual therapy in 2015 with steadily increasing numbers ever since. The results are that onchocerciasis is now:

  • almost completely eliminated from Latin America such that most of the mass drug distribution programmes have been able to stop.
  • The disease is on its way to elimination in … African countries.
  • Eradication is within sight
Remaining challenges

Whilst the stated aim of the WHO is to see onchocerciasis elimination in most of the endemic countries by 2025ref.there are several challenges to reaching the goal of eradication

  • There is a risk of donor fatigue, having achieved so much, the headline of effect is less impressive and donors may be looking for other avenues With subsequent faiure to see this through to completion In areas in which there is also the worm Loa Loa the use of ivermectin alone is not safe since it can result in severe neurological adverse events, hence these communities in Central African countries need identifying and given alternative treatment strategies
  • There is a risk of resistance to ivermectin however this may be helped by the recent license of a drug called albendazole for this treatment.
  • In some circumstances even CDTI is impractical, in particular countries with active conflict/war or natural disasters (famine, drought, epidemics).
  • A safe, single dose (or short course) drug which safely can kill the adult worms would significantly speed up elimination efforts.
What next

Eye health is in danger of becoming lost in a rush of COVID and other interests. I firmly believe this should not happen. Blindness is not only a burden to the person who has it but also a huge burden to those around who need to guide, feed and help care for those afflicted. Since 80% of the world’s blindness is preventable the cost effectiveness of interventions is huge. The ONLY surgical procedure to be judged cost-effective by the World Bank was cataract surgery. Be aware of the world of sight, your eyes will be truly opened!

 

If you would like to comment on any of the issues raised by this article, particularly from your own experience or insight, Healthcare-Arena would welcome your views.

 

References

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Article 2 of a 2 part series on the NHS. Co-authored by Deborah Glover

Original illustration for Healthcare-Arena by Fran Orford
Abstract

In the last article1 some of the challenges related to the acquisition and use of personal protective equipment (PPE) against the Covid-19 virus were raised. In response to some of the issues, particularly in relation to face and eye protection, the Government have asked industry to make essential PPE that meets certain technical specifications. This has provided an opportunity for novel products to be evaluated. In this article, one such product, the Virimask eye and face protection unit, will be presented and discussed.

Introduction

The images of personal protective equipment-induced pressure lines on the faces of health care workers are hard to comprehend. Sadly, the design of the equipment which is meant to protect can cause harm.

Coronavirus disease (Covid-19) virus is transmitted primarily through:

  • transfer of respiratory droplets carrying infectious pathogens to mucosal surfaces of a recipient, by sneezing, coughing or speaking
  • fomite – an object such as surfaces, inanimate objects, mobile phones, contaminated with infected organisms and which transmits them to another person

Thus, appropriate protective equipment is required to protect health care professionals from potential infection.

Current PPE challenges

Guidance on the use of PPE has been provided by Public Health England.2 However, there have been difficulties in availability and fit of PPE; for example, not all brands of filtering facepiece 3 (FFP3) masks fit in the same way2 and in order to meet Health and Safety Executive regulations, each mask requires fit testing, which can take up to an hour each time.3 In addition, Public Health England guidance states that both FFP3 and fluid-resistant (Type IIR) surgical masks (FRSM) facial masks are for single use or single session use. This places a burden on both supply and cost.4

As the virus can also be transmitted via the conjunctival epithelium5 and eye protection is associated with lower risk of infection6, well-fitted eye and face protection is required against eye from respiratory droplets, aerosols from aerosol generating procedures (AGPs) and from splashing of secretions (including respiratory secretions).4

Such protection is provided by single-use:

  • a surgical mask with integrated visor
  • a full face shield or visor
  • polycarbonate safety spectacles or equivalent

The technical specifications for face protection are outlined in table 1. Both FFP3 and FFP2 face masks should:7

  • conform to BS EN 149:2001+A1:2009 standards
  • cover the nose and mouth and the chin
  • may have inhalation and/or exhalation valve(s)
  • entirely or substantially comprise filter material
  • be packaged in such a way that they are protected against mechanical damage and contamination before use
  • subject to quality management systems such as evidence of compliance to ISO 9001 or BS EN 13485

Face shields or visors are worn on the head to cover the whole of the face and must:

  • be optically clear
  • be resistant to fogging
  • have an adjustable head band
  • be resistant to droplets and splashes

Eye shields and safety glasses have the same requirements. In addition, Public Health England guidance states that ‘it is important that the eye protection maintains its fit, function and remains tolerable for the user. Eye and face protection should be discarded and replaced and not be subject to continued use if damaged, soiled (for example, with secretions, body fluids) or uncomfortable’.4 However, re-usable eye and face protection can be used if it is decontaminated between single or single sessional use, according to the manufacturer’s instructions or local infection control policy.4,8

ViriMASK™ – a safe and effective environmentally friendly alternative to full-face PPE

The ViriMASK is strapped around the head; it covers the eyes with a see-through visor and the nose and mouth with protected with a disposable filtering component. The frame is made from elastic biocompatible materials with compliant sections according to the wearer’s face softness and is designed to fit snugly to the skin surface, eliminating pressure lines (figure 1). Made from fully recyclable TPE Virimask™ is a better environmental option than the plethora of plastic based masks and eye protection currently available. The replaceable filter cartridge contains pleated HEPA H14 filters and is sealed to the barrier frame.

Figure 1: The ViriMask - Image courtesy: Pentland Medical
Figure 1: The ViriMask – Image courtesy: Pentland Medical

The mask can be washed and reused, and although the filters, which come with a safety pouch for storage between uses, must be replaced after 60 hours of use, they can be disposed of safely via the envelope provided. It is designed to last a lifetime with good care, simply wash in soap and water or wipe with alcohol wipes. It provides:

  • an effective and safe seal; the mask is completely sealed to outside air penetration
  • higher filtration rating; protects against 99.99% particles compared to 95% in N95 mask
  • integrated eye protection; prevents infection/contamination through the eye
  • exceptional ventilation; the ViriMASK’s breathing area is 5X larger than others, and with its low air flow resistance, breathing is comfortable
  • superb personal comfort; minimal skin pressure for extended wear (and minimal pressure marks)
  • environmental care; the mask can be washed and disinfected, has easy filter replacement (after 60 uses), and used filters can be stored safely between uses and packaged for safe disposal
  • ease of use

Importantly, fitting is more comprehensive than the common one size fits all approach! Initial versions are available in two sizes designed to fit average male and female dimensions.

However, it will be possible in future to simply enter six measurements of the face into a website software sizing option, where an algorithm will calculate the size required for the individual which should even account for diverse ethnic or even disfigured morphological challenges.

There are many masks that include exhalation valves for added comfort. Virimask design omits this addition in the interests of maintaining the highest possible standard of mask integrity. Exhalation valves are not universally accepted for use, 4,9 City and County San Francisco for example.

It is recognised that exhaust valves can be a source of feedback and infection. 4,10 “The exhalation valve is, however, a vulnerable component of a respirator and under actual working conditions may become dirty or damaged to the point of causing significant leakage.”

Conclusion

Some of the challenges related to the acquisition and use of personal protective equipment have been raised in this article. The UK Government have asked industry to make essential PPE providing an opportunity for novel products to be evaluated. The product outlined in this article, the ViriMASK eye and face protection unit, is effective for the care of Covid-19 pandemic; however, as pathogenic threats are a continual threat, the ViriMASK can be stored ready for use in future threats. Interest in the Virimask solution is high not only in healthcare, but care homes, dental, and security staff. Other areas for consideration include transport, logistics and even large scale events management.

 

If you would like to comment on any of the issues raised by this article, particularly from your own experience or insight, Healthcare-Arena would welcome your views.

 

References
  1. Healthcare Arena, June 2020. https://healthcare-arena.co.uk/personal-protection-equipment-provision-challenges-and-solutions/
  2. Public Health England. Guidance COVID-19 personal protective equipment (PPE). May 2020. Available at: https://www.gov.uk/government/publications/wuhan-novel-coronavirus-infection-prevention-and-control/covid-19-personal-protective-equipment-ppe
  3. Health and Safety Executive. Fit testing face masks to avoid transmission during the coronavirus outbreak. HSE. 2020. Available at: https://www.hse.gov.uk/news/face-mask-ppe-rpe-coronavirus.htm
  4. NHS Providers. The Supply of Personal Protective Equipment. NHSP. April 2020. Available at: https://nhsproviders.org/media/689480/nhs-providers-briefing-spotlight-onthe-supply-of-personal-protective-equipment.pdf
  5. Cheng-wei Lu, Xiu-fen Liu, Zhi-fang Jia. 2019-nCoV transmission through the ocular surface must not be ignored. The Lancet. February 2020. 395;(10224):e39
  6. Chu DK, Akl E, Duda S, Solo K, et al. Physical distancing, face masks, and eye protection to prevent person-to-person transmission of SARS-CoV-2 and COVID-19: a systematic review and meta-analysis. The Lancet. 2020. DOI:https://doi.org/10.1016/S0140-6736(20)31142-9. Available at: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)31142-9/fulltext#seccestitle10
  7. HM Government. New High-Volume Manufacturers of COVID-19 Personal Protective Equipment (PPE) and Medical Device PPE. 2020. Available at: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/883334/Essential_Technical_Specifications__5_.pdf
  8. Coia JE, Ritchie L, Makison Booth C, et al. Guidance on the Use of Respiratory and Facial Protection Equipment. J Hosp Infect. 2013 Nov;85(3):170-82. doi: 10.1016/j.jhin.2013.06.020.
  9. https://sf.gov/information/masks-and-face-coverings-coronavirus-pandemic
  10. 1990 Oct;51(10):555-60. doi: 10.1080/15298669091370095. Aerosol Penetration Through Respirator Exhalation Valves P Bellin 1 , W C Hinds PMID: 2147535 DOI: 10.1080/15298669091370095 Cite Am Ind Hyg

Table 1: Current face PPE technical specifications (HSE Rapid Evidence Review. HSE. 2020. Available at: https://www.hse.gov.uk/news/assets/docs/face-mask-equivalence-aprons-gown-eye-protection.pdf)

Requirement FFP2 (EN149:2001+A1:2009) FFP3 (EN149:2001+A1:2009)
Assigned Protection factor (APF) 10 20
Filter efficiency ≥94%(95 l/min) ≥99%(95 l/min)
Total inward leakage (TIL) ≤8% ≤2%
Inhalation resistance ≤240Pa(95 l/min) ≤300Pa(95 l/min)
Exhalation resistance ≤300Pa(160 l/min) ≤300Pa(160 l/min)
Rebreathed CO2 ≤1% ≤1%

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Article 1 of a 2 part series on the NHS. Co-authored by Stewart Munro

Image courtesy: Pentland Medical
Introduction

January 20th 2020 was an auspicious day for two reasons; first, two Chinese nationals staying in York tested positive for Corona virus disease 19 (Covid-19) and second, an evacuation flight of British nationals arrived from Wuhan, and its occupants were placed into a 14-day quarantine at a specialist hospital.1

The World Health Organization consider that the virus is transmitted primarily through respiratory droplets and direct contact with infected people, and indirect contact with surfaces in the immediate environment or with objects used on the infected person.2 Accordingly, health care professionals (HCPs) need appropriate protective equipment to protect them from potential infection from an infected patient and to prevent cross-infection between patients in their care.

Which PPE?

In April 2020, Public Health England (PHE) updated its guidance on the use of PPE, including the reuse of certain pieces of equipment.3 It is not the intention of this article to consider this change either from a legal or moral view, rather to reflect the guidance as it stands at the time of writing. The PHE guidance lays out which equipment should be used by whom in which care setting and in accordance with risk-assessment. An example of the clinical areas where PPE is to be used and at what level is summarised below and in table 1.

Areas where aerosol generating procedures (AGPs) are undertaken
These include intensive care and/or high=dependency units, operating theatres, resuscitation areas of emergency departments and clinical areas where AGPs are performed, such as wards with non-invasive ventilation (NIV) or Continuous Positive Airway Pressure Ventilation (CPAP).

The AGP procedures deemed to be potentially infectious include (PHE 2020):

  • intubation, extubation and related procedures such as manual ventilation and open respiratory tract suctioning (including the upper respiratory tract)
  • tracheotomy or tracheostomy (insertion or open suctioning or removal)
  • surgery and post-mortems involving high-speed devices
  • non-invasive ventilation (NIV); bi-level positive airway pressure ventilation (BiPAP) and continuous positive airway pressure ventilation (CPAP)
  • high frequency oscillatory ventilation (HFOV), high flow nasal oxygen (HFNO)

In these areas, practitioners are required to wear a long-sleeved disposable fluid repellent gown/overall (covering the arms and body), a filtering face piece class 3 (FFP3) respirator, a full-face shield or visor and gloves for both possible and confirmed cases. Where an AGP is a single procedure, PPE is subject to single use with disposal after each patient contact or procedure as appropriate.

Inpatient areas with possible or confirmed COVID-19 cases
A fluid resistant surgical facemask (FRSM) (Type IIR) whether or not involved in direct patient care. Disposable gloves, aprons and eye protection should be worn if giving direct care. If there are no identified possible or confirmed cases, aprons, gloves and FRSMs may be indicated dependent on intensity of COVID-19 transmission in the local context and the nature of clinical care undertaken.

Operating theatres (no AGP undertaken)
Standard infection prevention control (IPC) should be adopted. Additional FRSM and eye protection is required for any possible or confirmed cases, and long-sleeved disposable fluid repellent gowns are indicated for possible and confirmed cases when there is perceived risk of exposure to bodily fluids.

Issues of PPE

According to a recent BBC report, the personal protective equipment (PPE) available to the front-line health care professionals caring for Covid-19 patients, is not particularly suitable for women, despite its ‘unisex’ design.4 In particular, for some female (and male) workers, the smallest size of gown is still too big, which compromises the effectiveness of the equipment, and gloves and goggles often are not produced in appropriate sizes. This problem of ‘female-sized’ equipment was highlighted in a 2017 Trades Union Congress report.5 Their survey found that 57% of women stated that their PPE sometimes or significantly hampered their work.5

The full-length gowns, gloves, masks and face-shields can become hot and uncomfortable to wear, particularly challenging on an eight or twelve-hour shift. In addition, the N95 mask, usually used in the United States of America, only comes in two sizes; most people’s faces don’t.

These issues arise because PPE is generally based on the sizes and characteristics of European and United States male populations, therefore most women, and some men from black and minority ethnic groups or with facial hair, will find that respiratory protective equipment, overalls, eye protectors, gloves and boots do not fit. A smaller size or scaled-down version of such equipment is not the solution; face and body characteristics need to be taken into account.

 

Continuing challenges relate to the well-documented difficulties on accessing personal protective equipment (PPE) in the United Kingdom.6 Acute care services were not alone in being affected; General Practitioners surgeries and other primary care settings faced problems (Box 1).

These problems are in part, due to the sheer number of pieces of equipment required. Consequently, emergency PPE may not be of the same brand usually used; for example, up to five different brands of FFP3 masks have been delivered.6 In order to meet Health and Safety Executive regulations each mask requires fit testing, which can take up to an hour each time.7

Public Health England guidance states that both FFP3 and fluid-resistant (Type IIR) surgical masks (FRSM) facial masks are for single use or single session use. This places a burden on both supply and cost.6

Well-fitted eye and face protection is required against eye from respiratory droplets, aerosols (from AGPs) and from splashing of secretions (including respiratory secretions).6

Such protection is provided by:

  • a surgical mask with integrated visor
  • a full face shield or visor
  • polycarbonate safety spectacles or equivalent

Again, this protective equipment is for single or single session use only. However, Public Health England suggest that re-usable eye and face protection can be used if it is decontaminated between single or single sessional use, according to the manufacturer’s instructions or local infection control policy.6

The current Covid-19 pandemic has also highlighted the enormous supply and demand issues caused by the first serious global pathogenic threat in a Century. The lack of genuine preparedness not only led to serious and perhaps unnecessary risk to health amongst frontline workers in healthcare, security, transport, etc, but also commercial exploitation and potential for negative environmental impact.

Conclusion

Some of the challenges related to the acquisition and use of personal protective equipment have been raised in this article. At the time of writing, Lord Deighton has been charged with heading a task-force to lead the national effort to produce essential personal protective equipment (PPE) for frontline health and social care staff. The Government have asked industry to make essential PPE that meets our technical specifications. This has provided an opportunity for novel products to be evaluated; one such product, the Virimask eye and face protection unit, will be presented in the next article in this series.

 

If you would like to comment on any of the issues raised by this article, particularly from your own experience or insight, Healthcare-Arena would welcome your views.

 

References
  1. Holmes F. Covid-19 Timeline. British Foreign Policy Group. April 2020. Available at: https://bfpg.co.uk/2020/04/covid-19-timeline/
  2. World Health Organization. Modes of transmission of virus causing COVID-19: implications for IPC precaution recommendations. March 2010. Available at: https://www.who.int/news-room/commentaries/detail/modes-of-transmission-of-virus-causing-covid-19-implications-for-ipc-precaution-recommendations
  3. Public Health England. Guidance COVID-19 personal protective equipment (PPE). May 2020. Available at: https://www.gov.uk/government/publications/wuhan-novel-coronavirus-infection-prevention-4. and-control/covid-19-personal-protective-equipment-ppe
  4. Kleinman Z. PPE ‘designed for women’ needed on frontline. Available at: https://www.bbc.co.uk/news/health-52454741
  5. Trades Union Congress. Personal protective equipment and women. 2017. Available at: https://www.tuc.org.uk/sites/default/files/PPEandwomenguidance.pdf
  6. NHS Providers. The Supply of Personal Protective Equipment. NHSP. April 2020. Available at: https://nhsproviders.org/media/689480/nhs-providers-briefing-spotlight-onthe-supply-of-personal-protective-equipment.pdf
  7. Health and Safety Executive. Fit testing face masks to avoid transmission during the coronavirus outbreak. HSE. 2020. Available at: https://www.hse.gov.uk/news/face-mask-ppe-rpe-coronavirus.htm

Box 1: Accessing PPE: A practitioner’s personal experience

This reflects the experience of a senior practitioner in a Clinical Commissioning Group. Given the potential issues arising from speaking truth to power, the author wishes to remain anonymous.

“We are in the 8th week of Covid 19 lock-down, yet guidance on what constitutes an appropriate PPE for general practices, the regularity of the supply chain and the escalation processes remain muddled and ineffective.

As per the national guidance, general practices are provided with surgical masks, aprons and gloves. The Government directed General practitioners (GPs) and Clinical Commissioning Groups (CCGs) to set up ‘hot zones’ and respiratory clinics to provide clinical services to patients with respiratory symptoms.  However, as full-length gowns and FFP3 mask supplies have been limited to those care services performing aerosol generating procedures, the GPs refused to work in the respiratory clinics due to the transmission risk.

Clinical Commissioning Groups and GPs are expected to source their own PPF3 masks, eye protection/face visors and surgical gowns. In addition, the processes required to order PPE via the national supply chain, and the escalation route through local resilience forum (LRF) should the normal supply chain are unable to provide the PPE in time, are failing. Daily feedback from the practices indicate that clinics are being cancelled due to lack of PPE; supplies are irregular and/or not of the amount requested, out of date, or the wrong size. PPE supply problem affects GPs and other parts of the health and social care systems; the lack of PPE in community home visiting services, secondary care and care home settings has often led to disruption of services, with local organisations arranging PPE for provider services at premium prices.

Sourcing PPE has almost become a full-time job for commissioners and providers which they could have done without. As the lock-down eases and more regular patient facing services are back up and running, situation will only get worse if the PPE national response does not improve soon.”

Tables

Table 1: Summary of PPE required in Clinical Areas

Areas where AGPs are performed Inpatient areas with possible or confirmed COVID-19 cases Operating theatres (no AGP undertaken)
Long-sleeved, fluid repellent gown (cover arms and body) At all times Where perceived risk of exposure to bodily fluids
Filtering face-piece (FFP3) respirator At all times
Full-face shield or visor At all times
Gloves At all times
Fluid-resistance surgical facemask (FRSM Type IIR) At all times Possible and confirmed cases
Disposable gloves Giving direct care
Disposable apron Giving direct care
Eye protection Giving direct care Possible and confirmed cases

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Image courtesy: Tali Yoga

I often describe yoga as being a bit ‘magical’. As a genetics-researcher-turned-yoga-teacher, it is no surprise to me how the benefits of the ancient practice of yoga are now being backed up by modern scientific research. The fields of movement science and neuroscience are fast accelerating, and it is fascinating to witness the emergence of yoga (and other mindfulness practices) as potential medical interventions.

Yoga practitioners frequently report a large cohort of benefits beyond increased strength and flexibility, and I here aim to summarise the evidence-based support for this. A quick search through peer-reviewed literature provides strong evidence that a consistent yoga practice can correlate with a vast array of health benefits. At a time where chronic health conditions are increasing at unprecedented levels and healthcare systems are struggling to cope, medical organisations are looking towards inexpensive interventions such as yoga to ease the burden. Yoga is an accessible and attractive option for many people, and shows enormous potential in improving health and wellbeing. National healthcare bodies, such as the NHS in the UK 1 and NIH in the US 2, are now recommending yoga for certain conditions, and there is a wealth of science-backed evidence to support this advice.

Yoga is an ancient Indian spiritual system which was thought to have originated over 5000 years ago. It is becoming a widely popularised practice, with yoga practitioner numbers in the US alone increasing from 20.4 million to 36 million between 2012 and 2016 3.

A common misconception, particularly in Westernised cultures, is that yoga is a purely physical movement system. However, the benefits of yoga are not limited to improved fitness, and the yogic tradition incorporates many more practices than asana (physical poses). In fact, there are only three asana aphorisms in the entirety of Yoga Sutras of Patanjali, one of the most pivotal yogic texts. The Yoga Sutras focus on other yogic practices, such as meditation, pranayama (breathwork) and sensory withdrawal, as well as following moral and ethical observances. In Western society most people practice hatha yoga, which combines asana, pranayama and meditation.

These tools of movement, breath and meditation come together to form a strong mindfulness practice. The breath is regulated and used as a focal point for the practitioner to bring his/her attention to which, when linked with movement, can have a strong physical ‘grounding’ effect. The practice of yoga has long been anecdotally linked with positive mental health and stress reduction for this reason. Research into yoga and other mind-body therapies (including Tai Chi, Qigong and meditation) and wellbeing, particularly psychological health, has proliferated in recent years. Yoga, mindfulness, meditation and breath awareness practices have also been incorporated into various healthcare programs, such as Mindfulness-Based Stress Reduction (MBSR) programs and Relaxation Response Resiliency Program (3RP).

Mind-body therapies have the potential to reduce healthcare utilisation, at a lower cost than a visit to the emergency room, hospitalisation or even other complementary and alternative medicine (CAM) therapies 4. 3RP, a mind-body medicine program designed by the Benson Henry Institute 5, was shown to decrease total healthcare utilization by 43% at one year of participation 6. This offers a ray of hope in the current epidemic of chronic disease.

Over 70% of all deaths worldwide are caused by chronic, or noncommunicable, disease 7. This huge cause of mortality is thought to be caused by four main behavioural risk factors; tobacco use, physical inactivity, alcohol intake and unhealthy diet. Although there has yet to be any large-scale studies on the potential of yoga in alcohol use disorder recovery, yoga at least offers promise as a complementary treatment in smoking cessation 8, and can also help promote healthy eating 9, as well as being a physical movement practice, particularly in the West.

The biochemical and neurological mechanisms underlying the correlation between yoga and improvements of various health conditions are now starting to be better understood. Emerging research into the impact of yoga on anxiety and unipolar depression shows promise, with putative biological and cognitive mechanisms implicated in this. Autonomic nervous system dysfunction has been shown to be linked with depression10 and anxiety11. There is evidence to suggest yoga can increase parasympathetic nervous system (PNS) activity and increase GABA levels in the thalamus, and these increases are correlated with improved mood 12.

The benefits of yoga are not limited to neurological and psychiatric improvements. Increased levels of inflammation are thought to be involved in many conditions such as fatigue, pain and depression 13. These symptoms are all highly responsive to mind-body therapies, which have been shown to reduce genomic markers for inflammatory signalling pathways.

Research exploring loneliness in older adults demonstrated a potential link between perception of loneliness and upregulated expression of pro-inflammatory genes in circulating leukocytes. The study also showed that participation in MBSR programs could reduce feelings of loneliness. Reduced gene expression of inflammation-related genes as a result of MBSR participation occurred in parallel with a decreased perception of loneliness. The NF-kB transcription factor, well known for its role in the expression of pro-inflammatory genes, in particular was down-regulated in MBSR practitioners 14. NF-kB also was shown to have consistently reduced activity amongst breast cancer survivors who practiced yoga 15.

Yoga clearly shows promise as a low-cost healthcare intervention, with the full number of reported benefits not limited to those described in this article. By making yoga and other mind-body therapies more accessible to a diverse range of populations, we may be able to reduce the burden on healthcare services and improve the quality of life of individuals suffering from a myriad of medical conditions. With this exponential rise in yoga-related research, I am eagerly awaiting an even deeper insight into the ‘magic’ that I continue to witness.

 

If you would like to comment on any of the issues raised by this article, particularly from your own experience or insight, Healthcare-Arena would welcome your views.

 

References

  1. https://www.nhs.uk/live-well/exercise/guide-to-yoga/
  2. https://nccih.nih.gov/health/yoga
  3. https://www.yogaalliance.org/2016yogainamericastudy
  4. Nahin RL, Barnes PM, Stussman BJ, Bloom B (2009) Costs of complementary and alternative medicine (CAM) and frequency of visits to CAM practitioners: United States, 2007. Natl Health Stat Report: 1–14.
  5. Park ER, Traeger L, Vranceanu AM, Scult M, Lerner JA, Benson H, et al. (2013) The development of a patient-centered program based on the relaxation response: the Relaxation Response Resiliency Program (3RP). Psychosomatics 54: 165–174.
  6. Stahl JE, Dossett ML, LaJoie AS, Denninger JW, Mehta DH, et al. (2017) Relaxation Response and Resiliency Training and Its Effect on Healthcare Resource Utilization. PLOS ONE 12(2)
  7. https://www.who.int/en/news-room/fact-sheets/detail/noncommunicable-diseases
  8. Beth C. Bock, Joseph L. Fava, Ronnesia Gaskins, Kathleen M. Morrow, David M. Williams, Ernestine Jennings, Bruce M. Becker, Geoffrey Tremont, Bess H. Marcus (2012) Yoga as a Complementary Treatment for Smoking Cessation in Women. J Womens Health (Larchmt) 21(2): 240–248
  9. Watts A.W., Rydell S.A., Eisenberg M.E., Laska M.N., Neumark-Sztainer D. Yoga’s potential for promoting healthy eating and physical activity behaviors among young adults: A mixed-methods study. Int. J. Behav. Nutr. Phys. Act. 2018;15:42
  10. Kop WJ, Stein PK, Tracy RP, Barzilay JI, Schulz R, Gottdiener JS. Autonomic nervous system dysfunction and inflammation con- tribute to the increased cardiovascular mortality risk associated with depression. Psychosom Med. Sep 2010;72(7):626-635.
  11. Dieleman GC, Huizink AC, Tulen JH, et al. Alterations in HPA-axis and autonomic nervous system functioning in child- hood anxiety disorders point to a chronic stress hypothesis. Psy- choneuroendocrinology. Jan 2015;51:135-150.
  12. Streeter CC, Whitfield TH, Owen L, et al. Effects of yoga versus walking on mood, anxiety, and brain GABA levels: a random- ized controlled MRS study. J Altern Complement Med. Nov 2010;16(11):1145-1152.
  13. Irwin MR, Cole SW. Reciprocal regulation of the neural and innate immune systems. Nat Rev Immunol. 2011;11(9):625–632
  14. Creswell JD, Irwin MR, Burklund LJ, Lieberman MD, Arevalo JM, Ma J, et al. Mindfulness-Based Stress Reduction training reduces loneliness and pro-inflammatory gene expression in older adults: a small randomized controlled trial. Brain Behav Immun. 2012;26(7):1095–1101.
  15. Bower JE, Greendale G, Crosswell AD, Garet D, Sternlieb B, Ganz PA, et al. Yoga reduces inflammatory signaling in fatigued breast cancer survivors: A randomized controlled trial. Psychoneuroendocrinology. 2014;43:20–2

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Image courtesy: Pentland Medical

Access to safe surgery is all but guaranteed for us in the Western world, in stark contrast to those in low income countries like Uganda, where there is only one trained surgeon per 200,000 people (compared to 70 in the UK). Travelling hundreds of miles to the nearest hospital with a surgical condition, only to be told that theatres are out of sterile linen, or that the trained anaesthetist is out of town, is the unfortunate reality for many Ugandans. Even those that do receive life saving surgery will seldom receive the close post-operative monitoring and treatment that are required.

As little as a decade ago, provision of surgical services remained all but off the agenda of international healthcare bodies and public health financiers – leading it to be described as the ‘neglected step-child of global health’ 1.

Since then, academics and policy makers have begun to recognise to the burden of surgical disease worldwide. Published in 2015, the Lancet Global Surgery Commission 2 saw a team of international commissioners and researchers, across 110 different countries research the availability of national surgical services. The results were startling:

  • Five billion people currently do not have access to safe and affordable surgery
  • 18 million preventable deaths occur each year from surgically treatable conditions (four times the mortality of HIV, TB and malaria combined)
  • There is a shortfall of 143 million operations a year worldwide

While the statistics seem to illustrate an insurmountable need, the cost-effectiveness of treating surgical conditions provides room for optimism. Surprisingly, surgical services more than pay for themselves in saved disability adjusted life years and subsequent economic growth. We know now that operations like repair of hernia or cleft lip + palate are far more cost effective than public health initiatives such as seatbelt awareness campaigns or even direct treatment of communicable diseases like HIV 3.

So now we’ve established how important and cost-effective surgical services in low and middle-income countries (LMICs) are, how do we best go about providing them? The answer is through a research-driven, simultaneous top-down and bottom-up approach.

Approach Description Examples
Top Down Mobilising surgical services on a national and international scale Lobbying governments to prioritise healthcare and in particular surgical services in budgets with National Surgical Obstetric and Anaesthesia plans e.g. Zambia 2017

Countrywide incentives to retain skilled practitioners in more rural areas

Global research collaboratives such as GlobalSurg 4

Bottom Up Identifying local needs by working with surgical, anaesthesia and nursing staff on the ground Medium to long term exchange programmes and international placements for LMIC doctors to gain skills overseas and vice versa

Funding grassroots surgical charities and NGOs with local surgeons and effective training programmes e.g. Smile Train and CURE

Directly supporting small initiatives with important and short term aims such as this years e.g. building theatres, sponsoring surgical trainees through training

Through these measures we can ensure evidenced based solutions to providing safe and affordable surgery through a national and local means, country-by-country and hospital-by-hospital. Being sure to engage and work alongside existing excellent practitioners and policy makers and avoiding the mistakes of the past 5.

My personal involvement in global surgery began in June this year when I took a break from surgical training and travelled to Uganda to undertake a volunteer placement with the general surgery team in Mbale Regional Referral Hospital (Mbale RRH), a government hospital 120 miles east of Kampala.

I wanted to experience surgery in the developing world first hand, and find out where the real needs and gaps in care were. Working alongside Ugandan doctors and nurses, sharing experiences and learning from each other.

At the time of writing I am 6 months into a 9-month placement. My time is split between the wards, outpatient clinic, endoscopy and the operating theatre. There are two local senior general surgeons who are both very capable and experienced but with more a 50-bed ward and more than 1000 major operations taking place a year, they are quite simply overwhelmed. This means they often have to leave junior doctors to undertake emergency cases and part of my role has been supporting the juniors where needed. The work is tiring but unquestionably rewarding.

Working here has given me a candid view of the frontline of healthcare in the developing world. Supplies of drugs and sundries are limited and while healthcare provision is theoretically free, patients will often have to purchase their own antibiotics, sutures or surgical gloves. The hospital is the busiest of its kind in Uganda and serves a population of 4.7 million spread over a wide catchment area, meaning many patients present very sick indeed – sometimes several days into a life-threatening illness. This means patients are often in a bad way prior to their emergency surgery and while the capacity to perform the surgery is there, attentive post-operative care is not. There is no intensive care unit (ICU) here in Mbale so the sickest post-operative patients are cared for alongside everybody else on a 50-bed ward staffed with 1 nurse.

Comparing surgical outcomes data in Mbale with developed countries helps illustrate the importance of good post-op care. Below is data representing outcomes in emergency laparotomy (operation for people with abdominal complaints, finding the cause and treating it) from a recent yearlong audit in Mbale 6, with those from the most recent UK-wide National Emergency Laparotomy Audit 7:

Location No. of cases Mean age High risk patients admitted to ICU Mortality
Mbale RRH 304 25 years 0% 22.4%
UK-wide 24,897 67 years 55% 10.6%

Twice the numbers of patients are dying after emergency surgery in Mbale than the UK despite being half the age of patients in the UK. These statistics are upsetting, but with the theme of quality bottom-up surgical services improvement, a team of us at Mbale have set up a project that we hope will vastly improve things – a new high dependency unit to give patients the post-op care that they deserve.

Providing safe and affordable surgery for the 5 billion will be no easy task, but we can all do our bit to support those in desperate need and provide the high quality healthcare that we in the Western world take so easily for granted. You can help do your part by making a donation to the RCS Christmas Appeal and help us build a much-needed surgical high-dependency unit here in Mbale. You can read more and donate using the link below. Donations will be accepted well into 2019. Thank you.

https://www.rcseng.ac.uk/about-the-rcs/support-our-work/donate/christmas-appeal-2018/

 

If you would like to comment on any of the issues raised by this article, particularly from your own experience or insight, Healthcare-Arena would welcome your views.

 

References

  1. Farmer PE, Kim JY. Surgery and global health: a view from beyond the OR. World J Surg 2008; 32: 533–36
  2. Meara JG, Leather AJM, Hagander L, Alkire BC, Alonso N, Ameh EA, et al. Global Surgery 2030: Evidence and solutions for achieving health, welfare, and economic development. Lancet. 2015; 386: 569–624.
  3. Grimes CE, Henry JA, Maraka J, Mkandawire NC, Cotton M. Cost-effectiveness of surgery in low- and middle-income countries: a systematic review. World J Surg. 2014; 38(1):252-63
  4. www.globalsurg.org
  5. epuis CC. Humanitarian missions in the third world: a polite dissent. Plast Reconstr Surg 2004; 113:433–35.
  6. Hewitt-Smith A, Bulamba F, et al. Surgical outcomes in eastern Uganda: a one-year cohort study. South African Journal of Anaesthesia and Analgesia. 24(5): 122-127
  7. https://www.nela.org.uk/reports