Can gendered personal protective equipment design account for high infection rates in female healthcare workers following intubation?

Female sex was identified in the study by El‐Boghdadly et al. as an independent factor for proven or suspected COVID‐19 infection of healthcare workers following intubation [1]. As one of the significant findings outlined in the paper, it was surprising to us that this was not given more prominence in the discussion or the infographic associated with the article.

Whereas it is clear that this association does not necessarily amount to causation, a hazard ratio of 1.36 (p = 0.04) is substantial enough to compel further exploration. It is unlikely that the finding of increased reporting in women can be attributed to a female predisposition to SARS‐CoV‐2 infection as this has not been demonstrated elsewhere in the literature. In sex disaggregated data of over 1.3 million cases reported world‐wide, there are no marked gender differences in rates of COVID‐19 infection in the general population in 18 countries, with an overall rate of 51.2% female [2]. Why then is the post‐intubation healthcare worker infection rate so notably skewed towards women?

El‐Boghdadly et al. propose that ‘biological differences’ may be a factor in this disparity, without elaborating further. We postulate that one biologically relevant difference could be body habitus and the gendered design of personal protective equipment (PPE). Personal protective equipment has been noted in other sectors, such as mining and engineering, to be designed for the male body shape [3]. It stands to reason that this may also be the case in the health sector, and studies by the Royal College of Nursing and ergonomists are underway to investigate.

The COVID‐19 outbreak has brought these issues to the attention of the UK media, where anecdotes of sex disparity in the appropriate fit of PPE have been proffered from various NHS sources [4, 5]. Stories abound within healthcare about ‘unisex’ (for which read: inadequately sized) PPE – gowns so large that they drag on the floor and trip up the wearer, gloves that are not available in small enough sizes, visors that are dislodged by breasts when the intubator looks down, and ill‐fitting facemasks and goggles that fail to seal when applied to smaller female faces. Such PPE, whereas not being fit for purpose when worn, may also prove more difficult (and therefore more dangerous) to doff.

Women comprise over three‐quarters of healthcare workers in the UK and many other countries. Failure to adequately protect a large sector of the workforce is ethically unsound, a health and safety issue, and a looming potential class action lawsuit. Urgent research is needed to ascertain the extent of the problem, and immediate action is required to ensure sex equity in PPE provision.