Lack of protective gear disrupts oncology care.

A recent crowdfunding campaign caught the attention of Scottish actor James McAvoy, who was inspired to donate £275 000 to the campaign. Coined Masks for NHS Heroes, the physician-led initiative is raising money to increase the amount of certified one face masks, visors, surgical gowns, and gloves that are available to health-care workers caring for patients with coronavirus disease 2019 (COVID-19).

The outpouring of support from the public has been enormous. The original goal was to raise £200 000, but given the response, they kept the fund going. In their appeal, the doctors note that: “Unfortunately current hospital supplies are not sufficient and while we are reassured the government is doing everything it can, health-care workers on the frontline are risking themselves daily without adequate protection to care for sick patients. Health-care workers on the frontline without PPE [personal protective equipment] is the equivalent of going to war without armour and protection.”

The new target was increased to £1 500 000 and the campaign has reached this target (by April 8).

The availability of PPE is largely taken for granted by health-care personnel who work in high-income countries, but the advent of COVID-19 set off a global frenzy to secure supplies that would be needed to provide appropriate protection to health-care workers. Hospitals and health systems generally maintain their own stockpiles of PPE, but the growing pandemic has strained their supplies. As a result, facilities have developed protocols to conserve limited supplies, such as reusing items that would normally be discarded after use. Modelling done by WHO estimated that 89 million medical masks, 76 million examination gloves, and 1·6 million goggles would be needed for the COVID-19 response every month. WHO guidance also called for the “rational and appropriate use” of PPE for health-care workers and effective management of supply chains.

In a response to the current PPE shortage, Dame Donna Kinnair, Chief Executive and General Secretary of the Royal College of Nursing, said that even though “the government is finally prioritising COVID-19 testing for NHS staff, including social care, it is completely unacceptable that weeks into this crisis, there are colleagues in all settings—hospitals, community, or care homes—who have not been provided with PPE.”

She added, “I am hearing from nurses who are treating patients in COVID-19 wards without any protection at all. This cannot continue. They are putting themselves, their families, and their patients at risk.”

Although much of the attention has focused on PPE use for COVID-19, the shortage has also affected cancer care, where it is used for both patient and health-care worker protection. The use of chemotherapy-tested gloves, single-use disposable gowns, respirators or masks, eye protection, and closed-system transfer devices are recommended to protect nurses and pharmacists against unintentional exposure to antineoplastic drugs, and protective gear is required to care for patients with cancer who are in isolation or during certain procedures.

“They are not just for preventing infection but are needed for protecting the health-care workers and anyone handling hazardous drugs,” said Julia M Challinor, an international nursing consultant for oncology. “There is no gold standard on how to measure exposure, but we do know that it's not okay to be exposed every day.”

The idea is also to prioritise equipment, Challinor noted. Face masks, for example, are prioritised for health-care workers at the highest risk of acquiring an infection, but the nurses working on the bone marrow transplant unit also need them.

Disruptions in care

Patients with cancer are at a high risk of severe COVID-19 disease if they become infected with the virus, and decisions have to be made to reduce their exposure to the virus. “But we have to balance the risk of exposure with the risk of not treating or undertreating patients,” Challinor said.

Additionally, facilities also reallocated resources to treat patients with COVID-19, which has resulted in disruptions in routine cancer care. Guidelines from professional organisations, such as the American Society of Clinical Oncology, suggest implementing protocols that delay elective surgeries, switching from intravenous to oral therapies if possible (to decrease the frequency of clinic visits), or modifying or withholding chemotherapy depending on the situation. But as the number of patients with COVID-19 increases, many hospitals have deferred all but the most urgent treatment to conserve staff and equipment.

However, cancer care cannot be stopped for most patients, and nurses and other personnel caring for patients need appropriate PPE. The situation in the UK and elsewhere is variable across the board. “Oncology nurses are reporting shortages in PPE only in some hospitals,” said Annie Young (University of Warwick, Coventry, UK). “The UK Oncology Nursing Society is signposting oncology nurses to many resources on coronavirus and cancer to protect their patients and oncology nurses from coronavirus.” The US Oncology Nursing Society (ONS) has acknowledged that nurses working in cancer care are facing difficult choices if the recommended PPE supplies are not available to them. “They are making choices regarding the protection of themselves and their patients from potential COVID-19 infection and use of PPE for safe handling of hazardous cancer drugs,” says the ONS. In response to this crisis, the ONS has issued “interim guidelines” for PPE use in oncology settings where PPE supplies might be limited.

The Royal Marsden Hospital in London (UK) has confirmed that that they “have a good supply of PPE, distributed across the hospital according to the latest national guidelines.” The Royal Free London NHS Trust Foundation also reports no issues with PPE.

Elaine Tomlins, consultant oncology nurse, stated that at a hospital on the South Coast of England, the oncology unit has moved to a private hospital where there is no COVID-19 care at the current time. But there are PPE shortages across the hospital and disinfectant wipes are not available for routine care in oncology.

“A District General Hospital in the West Midlands is also reporting shortages in the oncology unit,” said Young.

Facing termination

About 9% of COVID-19 cases in Italy, a country that has been hit hard by the virus, are health-care workers. An even larger proportion has been reported in Spain, where nearly 14% of people affected are medical professionals. Hundreds of health-care workers around the world have died from COVID-19, and the lack of proper protection might have had a role in it. However, many workers do not speak up about the lack of PPE for fear of losing their jobs.

In New York City, NY, USA, Ania Ringwelski, an emergency room physician at Weill Cornell Medical Center, did not feel that the PPE supplied by the facility was adequate so she obtained her own. The hospital would not permit her to use it and sent her home. In another US city, Chicago, IL, Lauri Mazurkiewicz, a nurse working at Northwestern Memorial Hospital, had been warning her coworkers that the standard face masks being distributed by the hospital were not safe for caring for patients with COVID-19. She brought in her own N95 mask and was fired by the hospital for doing so. Mazurkiewicz is now suing Northwestern.

Many health-care workers have taken to social media to discuss the situation with their colleagues and to publicise the conditions under which they are being forced to work. In turn, hospitals have threatened to fire employees who publicly speak about their working conditions and lack of PPE. In one instance, an emergency room doctor in Bellingham, WA, USA, openly discussed the conditions at the facility where he was employed. Ming Lin had worked at PeaceHealth St Joseph Medical Center for 17 years and was terminated when he pleaded for safer working conditions for staff.

Two health-care systems in New York City, NYU Langone and Montefiore Health System, have sent all employees memos reminding them of policies that all media requests must go through the public relations department. NYU Langone also added that employees would be “subject to disciplinary action, including termination,” if they did not comply.

A similar situation has been reported in the UK, where according to evidence collected by the Doctors' Association UK (DAUK), NHS staff are being “gagged” from speaking out about widespread shortages of PPE. Both physicians and nurses have been warned by hospitals and other NHS facilities that they cannot discuss their concerns publicly. One of the testimonies given to DAUK was from an intensive care physician who was concerned about the facemasks, but was told by the hospital that “if we hear of these concerns going outside these four walls your career and your position here will be untenable”.

Future concerns

The US Centers for Disease Control and Prevention (CDC) has issued guidelines to optimise the use of PPE under the current situation. However, these recommendations are not specific to oncology care, Challinor pointed out. “Considering that the landscape is changing daily, this is an urgent situation, since hospitals have not faced PPE shortages in the US ever before, so there are no studies showing what is appropriate action,” she said. “What I am afraid of, is that governments in low-income and middle-income countries in the future will say they do not have to buy PPE for oncology nurses because they saw US government agencies recommending homemade PPE for COVID-19 and so they should be fine for oncology as well. What people in general do not realise is that this is not what the CDC is saying. We do not want governments to be thinking that if it is good enough for COVID-19, it is good enough for chemotherapy,” she added.