Availability of personal protective equipment and diagnostic and treatment facilities for healthcare workers involved in COVID-19 care: A cross-sectional study in Brazil, Colombia, and Ecuador.

Many affected counties have had experienced a shortage of personal protective equipment (PPE) during the coronavirus disease (COVID-19) pandemic. We aimed to investigate the needs of healthcare professionals and the technical difficulties faced by them during the initial outbreak. A cross-sectional web-based survey was conducted among the healthcare workforce in the most populous cities from three Latin American countries in April 2020. In total, 1,082 participants were included. Of these, 534 (49.4%), 263 (24.3%), and 114 (10.5%) were physicians, nurses, and other professionals, respectively. At least 70% of participants reported a lack of PPE. The most common shortages were shortages in gown coverall suits (643, 59.4%), N95 masks (600, 55.5%), and face shields (569, 52.6%). Professionals who performed procedures that generated aerosols reported shortages more frequently (p<0.05). Professionals working in the emergency department and primary care units reported more shortages than those working in intensive care units and hospital-based wards (p<0.001). Up to 556 (51.4%) participants reported the lack of sufficient knowledge about using PPE. Professionals working in public institutions felt less prepared, received less training, and had no protocols compared with their peers in working private institutions (p<0.001). Although the study sample corresponded to different hospital centers in different cities from the participating countries, sampling was non-random. Healthcare professionals in Latin America may face more difficulties than those from other countries, with 7 out of 10 professionals reporting that they did not have the necessary resources to care for patients with COVID-19. Technical and logistical difficulties should be addressed in the event of a future outbreak, as they have a negative impact on healthcare workers. Clinical trial registration: NCT04486404.

Introduction

On December 31, 2019, several cases of pneumonia of unknown etiology in Wuhan were reported by the People’s Republic of China to the World Health Organization (WHO). Later, the causative agent was found to be a novel coronavirus, which was subsequently called severe acute respiratory coronavirus 2 (SARS-CoV-2). Infection with SARS-CoV-2 can result in coronavirus disease (COVID-19), which presents with respiratory and other symptoms [1]. On March 11, 2020, the WHO declared the COVID-19 outbreak to be a global pandemic [2].

On February 26, 2020, the first case of COVID-19 was registered in South America [3]. Since then, the number of confirmed cases has increased to 8,703,722, with 272,278 deaths (as of October 14, 2020). Brazil, Ecuador, and Colombia are among the most affected countries worldwide [4].

Healthcare networks in the most affected cities have exceeded their operational capacity [5]. This has highlighted a number of challenges posed by the excessive demand for care, hospitalization, intensive care, and management of patients suspected or confirmed to have COVID-19. Furthermore, special biosecurity and protection measures are required to protect the healthcare workforce.

Several studies have demonstrated that healthcare workers worldwide have been facing an overwhelming workload, lack of personal protection equipment (PPE), lack of ventilators and drugs, and a feeling of inadequate support due to the COVID-19 pandemic [6, 7]. This situation has generated deep concern among health and administrative workers, with some institutional measures being implemented to counteract these concerns. Additionally, the availability of PPE and of protocols standardizing its proper use vary. Due to an increased perception of self-risk (according to recent data, the perceived risk is up to two times higher than that in the general population), the demand for PPE is high [8].

In a worldwide survey, only 3% of the 2,711 included healthcare workers were from South America, and up to 52% of all participants reported the unavailability of at least one piece of standard PPE [9]. For instance, in the United States, the Food and Drug Administration and the Centers for Disease Control and Prevention have adopted several measures to optimize PPE use due to its shortage [10, 11]. Even though professionals consider that they have been well prepared for the pandemic in Germany, substantial differences in PPE availability have still been reported, depending on the setting (ambulatory or maximum-care hospitals) [12]. In Spain, 54% of primary care healthcare workers have not been adequately trained regarding how to use PPE [13]. A recent study found that the use of standardized PPE, including protective suits, masks, gloves, goggles, face shields, and gowns, could reduce the risk of contagion [14].

PPE shortages and the lack of preparedness have been reported as common issues in most affected countries [15]. However, the healthcare systems in South America are weaker than those in regions with stronger economies and more healthcare funding. No studies have considered this issue, and there is no data on PPE availability, diagnostic testing of professionals, and training in South American countries during the COVID-19 pandemic.

This study aimed to examine PPE shortages and the level of preparedness in South America from the perspective of healthcare professionals in South American countries [16]. In addition, this study aimed to examine the training and other needs of healthcare workers and the technical difficulties faced by them during the initial outbreak.

Materials and methods

A cross-sectional study was conducted during the first phase of the pandemic among the healthcare workforce from Brazil, Colombia, and Ecuador. Participation was voluntary and anonymous. This study was carried out in accordance with the Declaration of Helsinki and the normative and ethical regulations of the participating countries. The participants provided online informed consent prior to the survey. The ACCADEMY group guide for self-administered surveys of clinicians was followed [17].

Survey instrument

A survey was developed by a focus group using virtual communication channels. This technique has been used previously in other studies with satisfactory results and was primarily used due to social distancing requirements [18, 19]. Medical doctors from different hospitals in the city of Guayaquil, Ecuador, were included. A list of difficulties faced in patient care during the COVID-19 outbreak was compiled at the meeting. This was later checked by the research teams in Colombia and Brazil and adapted cross-culturally.

These emergent themes were used to create a digital survey with different questions, including multiple-choice questions, questions involving the listing of priorities, and open questions, to obtain qualitative information. There were no personal questions or questions regarding site-specific work conditions to preserve privacy and ensure the protection of personal data. In addition, the option to prevent the input of duplicate answers was enabled.

The survey content was submitted to a discussion group made up of six physicians; this group was different from the focus group in Ecuador. Modifications and changes were proposed by this group to improve the questions, reduce errors, and improve legibility. Furthermore, the content and readability were checked by two researchers in Colombia. The questions were translated and cross-culturally adapted following Beaton’s recommendations [20]. This same process was also undertaken by two other researchers who were fluent in Spanish and Portuguese; then, the content and readability were checked by a small group of Brazilian healthcare workers.

The survey had 14 questions, and the completion time was 6 minutes on average. Themes and obstacles were identified and grouped according to the following emergent themes: the number of staff; PPE (following WHO recommendations [21] for different levels of exposure or procedures involved), resources for appropriate patient treatment, availability of equipment, COVID-19 protocols, handling of personnel with suspected infection, and training (S1 File).

Participants

According to the official statistics, as of 2019 (latest available data), there are 82,009, 168,810, and 691,350 healthcare professionals (including physicians and nurses) in Ecuador, Colombia, and Brazil, respectively. Therefore, there was an estimated pool of 942,169 healthcare professionals [22, 23]. The sample size of 829 respondents was defined using the formula for infinite universes, with a 99% confidence level, 5% accuracy (p = q = 50), and 20% of lost data. At least 340 participants were required from each country for the sample to be representative. The target population of the survey was healthcare workers of any discipline or training background who were caring for patients with COVID-19. These healthcare workers included physicians (medical doctors who have completed a specialization, are undergoing training for a specialization, or are working as general doctors), nurses, auxiliary nurses, and other professionals (psychologists, physiotherapists, and respiratory therapists). Participants were required to specify their area of work and to specify whether the institution was a part of the public health system or a private hospital. Healthcare workers from different cities in each country were invited to participate so as to include a more representative sample. Participants were divided into two groups: performance of aerosol-generating (those working in intensive care units, general wards, and emergency departments) and no performance of aerosol-generating procedures (those providing primary care and radiology services). This categorization was performed as aerosol-generating procedures are associated with an increased risk of infection and normally require additional PPE.

Survey administration

We used Surveymonkey®, a web-based survey platform (SurveyMonkey Inc., San Mateo, USA), which prohibited the duplication of answers using internet protocol address information. A non-random, purposive sample of participants was invited from April 4 to May 7, 2020, using an e-mail database of over 3,000 people, social media, and instant messaging applications. Data collection continued until an adequate number of healthcare workers from each of the participating countries had been surveyed for the sample to be considered representative.

Data management and analysis

Descriptive analysis was conducted using IBM SPSS Statistics (IBM Corp. Released 2017. IBM SPSS Statistics for Windows, Version 25.0. Armonk, NY: IBM Corp). The results for each item were reported according to each participating country or according to different healthcare professions. An inferential analysis was conducted using the chi-square test to compare specific variables (public and private hospitals, exposure to high-risk procedures, and professional categories). A p-value of <0.05 was considered statistically significant (confidence intervals at 95%). Comments were extracted from the open text questions in the survey and analyzed by theme, most frequent narratives, and participants' perceptions of other obstacles.

Results

In the study period, 1,153 responses were collected, but only 1,082 were considered valid and included in the analysis. Of the 1,082 participants, 352 (32.5%), 389 (36%), and 341 (31.5%) were from Brazil, Colombia, and Ecuador, respectively. Overall, 538 (49.7%), 273 (25.4%), and 145 (13.4%) participants worked in public hospitals, private hospitals, and primary care units, respectively. Overall, 324 (30%), 295 (27.3%), and 278 (25.7%) worked in a hospital emergency department, hospital ward, and hospital primary care unit, respectively. A total of 755 (70.4%) participants worked in areas where aerosol-generating procedures were performed. In Ecuador and Colombia, the sample consisted mostly of physicians; in contrast, the sample in Brazil consisted mostly of nurses (Table 1).

Table 1

Participants description.

	Brazil		Colombia		Ecuador
	n = 352		n = 389		n = 341
Type of institution	n	%	n	%	n	%
Public institutions	281	79.8	134	34.4	268	78.6
Private institutions	71	20.2	255	65.6	73	21.4
Professional group
Physician	2	0.6	238	61.2	294	86.2
Nurse	191	54.3	54	13.9	18	5.3
Nursing Assistant	145	41.2	23	5.9	3	0.9
Others	14	4.0	74	19.0	26	7.6
Work area
Emergencies	75	21.3	104	26.7	145	42.5
Hospital ward	91	25.9	126	32.4	78	22.9
Intermediate or Intensive Care Unit	40	11.4	63	16.2	33	9.7
Radiology services	9	2.6	20	5.1	10	2.9
Primary care	137	38.9	76	19.5	65	19.1
Works in an aerosol-generating service
Presence	206	58.5	293	75.3	256	75.1
Absence	146	41.5	96	24.7	75	22.0

Resources for appropriate diagnosis and treatment

In total, 756 (70%) participants reported a lack of resources for diagnosing and treating patients with COVID-19. Emergency department and primary care staff reported greater shortages in medicines and equipment for diagnosing and treating patients with COVID-19 than those working in hospital-based wards and intensive care units (ICUs; S1 Table).

Professionals from public institutions who worked in areas where aerosol-generating procedures were performed reported higher resource shortages than those working in private institutions (p<0.001; Table 2).

Table 2

Lack of resources in the opinion of professionals working in areas of activity that perform procedures that generate aerosols, according to the type of institution.

	Public institutions n = 460/755 (60,9%)		Private institutions n = 295/755 (39,1%)		p-Value
	n	%	n	%
In general, during your previous workdays, during the care of a patient with possible respiratory affection, did you modify your therapeutic or diagnostic behavior for any of the following reasons? You can choose more than one.
Unavailability of necessary medication	141	30.7	49	16.6	<0.001
Lack of access to non-invasive ventilatory support (oxygen, cannulas, humidifiers, masks)	117	25.4	45	15.3	0.001
Lack of access to intensive care or invasive mechanical ventilation (ventilator)	178	38.7	61	20.7	<0.001
Lack of access to necessary diagnostic imaging tests	129	28.0	47	15.9	<0.001
Lack of access to necessary laboratory tests	177	38.5	75	25.4	<0.001
I have had the necessary to diagnose/treat patients	103	39.8	137	57.1	<0.001

Only participants working in areas where aerosols were generated were included in this analysis (n = 755).

PPE

Only 145 (13.4%) participants considered that they had adequate PPE for treating patients with COVID-19. In particular, 643 (59.4%), 600 (55.5%), and 569 (52.6%) participants reported shortages of gown coveralls, N95 masks, and face shields, respectively (S2 Table).

Among participants who worked in areas where aerosol-generating procedures were performed, 448 (59.3%), 384 (50.9%), and 372 (49.3%) reported the lack of special closed suits, N95 type masks, and face protectors, respectively. In total, 92 (29%) professionals who did not perform aerosol-generating procedures said they did not have surgical masks. Only 109 (21.8%) participants who performed aerosol-generating procedures and 36 (14.9%) participants who did not perform such procedures said they had the necessary equipment to adequately care for patients with COVID-19 (Table 3).

Table 3

Lack of personal protective equipment according to whether they performed procedures that generated aerosols.

	Performed n = 755/1072 (70,4%)		Did not perform n = 317/1072 (29,6%)		p-value
	n	%	n	%
In general, what protective equipment was needed to care for patients suspected of having respiratory problems during your shift or care days, and have you been unable to obtain it? You can choose more than one.
Gloves	106	14.0	68	21.5	0.003
Hat	124	16.4	84	26.5	<0.001
N95 type mask	384	50.9	209	65.9	<0.001
Disposable gown	244	32.3	146	46.1	<0.001
Disposable shoe protectors	253	33.5	154	48.6	<0.001
Face shield	372	49.3	194	61.2	<0.001
Clear protective glasses	183	24.2	126	39.7	<0.001
Special protective closed suit	448	59.3	190	59.9	0.9
Biocidal hydroalcoholic solution	80	16.0	52	21.5	0.07
Disposable surgical mask	160	21.2	92	29.0	0.006
I’ve had adequate and sufficient PPE	109	21.8	36	14.9	0.03

Data represent equipment that respondents were reporting as unavailable.

Up to 141 (13%) participants reported that they had to supply their own PPE (obtained through personal means). Furthermore, 528 (48.8%) participants stated that they reused PPE after it had been sterilized by themselves or at their workplace. The rest of the participants reported that they disposed off the PPE after use.

Obstacles faced by healthcare workers

The lack of diagnostic tests and PPE were prioritized (on a scale of 0–10) by the participants as the main obstacles faced while caring for patients with COVID-19. Fig 1 details the other obstacles reported by the participants.

Fig 1

Main obstacles when caring for patients with COVID-19.

Training on how to use PPE and awareness of relevant protocols

Up to 556 (51.4%) participants reported that they had not been trained on the correct use of PPE. Of these participants, 360 (64.7%) worked in public institutions and 196 (35.3%) worked in private institutions (p<0.001).

In total, 996 (92%) participants acknowledged that a protocol was used at their workplace to care for patients with COVID-19. The national guidelines were the most frequently used (570, 52.7%), followed by protocols developed by the institution (226, 20.9%). However, the technical, logistical, and inventory-related limitations inherent to the workplace comprised the main difficulties encountered in implementing these protocols (476, 44%). Moreover, 291 (26.9%) participants were unaware of whether such protocols existed (Table 4). Professionals working in public institutions considered themselves less prepared than those working in private institutions (p<0.001).

Table 4

Training for correct use of PPE and use of protocols for the care of COVID-19 patients.

	Doctor		Nurse		Nursing Assistant		Others		p
	n = 534/1082 (49,4%)		n = 263/1082 (24,3%)		n = 171/1082 (15,8%)		n = 114/1082 (10,5%)
	n	%	n	%	n	%	n	%
Have you received any training on how to use personal protective equipment?
Yes, it was enough	126	32.1	125	48.3	74	43.4	38	39.2	0.003
Yes, but it was insufficient and I would like to receive clearer information	177	45.2	85	32.8	65	38	43	44.3
I don't have enough training	89	22.7	49	18.9	32	18.7	16	16.5
What type of standardized protocols or guidelines for the care of patients with suspected respiratory illness or COVID-19 are used in your center?
I don't know or we don't have protocols for common use	50	9.4	10	3.8	20	11.7	6	5.3	0.005
Private protocols exclusive to my center	91	17.0	67	25.5	38	22.2	30	26.3
National Protocols	287	53.7	145	55.1	78	45.6	60	52.6
Guides to global health organizations, societies or institutions abroad	106	19.9	41	15.6	35	20.5	18	15.8
If you have protocols or guidelines, what do you consider to be the main obstacle to their implementation? You can choose more than one.
Lack of habit for using protocols or unawareness of it.	119	22.3	80	30.4	49	28.7	43	37.7	0.002
It is not possible to follow them due to the limitations of the center	281	52.6	84	31.9	59	34.5	52	45.6	<0.001
They change frequently and I can't keep up	86	16.1	70	26.6	31	18.1	24	21.1	0.005
I have no obstacle to applying the protocols	67	27.9	92	37.6	64	38.1	27	30.7	0.07

Handling of personnel with suspected or confirmed infection

In the scenario that a frontline professional presented with symptoms associated with COVID-19, 632 (58.4%) participants reported that their workplace arranged for reverse transcriptase-polymerase chain reaction (RT-PCR) testing for SARS-CoV-2 and isolated the affected staff members.

In total, 276 (25.5%) professionals had to undergo a SARS-CoV-2 test on their own (not arranged by the workplace) and had to continue working until the result was obtained. Most of these professionals worked in public hospitals (168, 60.9%), followed by private hospitals (67, 24.3%) and primary care (17, 6.2%) (p>0.05).

Moreover, 346 (32%) participants who had close contact with a patient suspected or confirmed to have COVID-19 without adequate protective measures said that they had to continue working in the absence of symptoms. In total, 736 (68%) participants were able to maintain preventative isolation, although there were different criteria regarding the duration of isolation (7, 14, and 21 days according to different protocols).

Qualitative analysis

Most of the participants focused on (1) the lack of PPE and the reuse of this equipment: “Reuse of disposable gowns and smocks, they are washed and reused, the N95 mask has to last us a week;” (2) the emotional overload caused by the pandemic in staff members, for which they lacked the necessary preparation: “the fear, and all the mental and emotional affectation by the situation;” (3) and in the independent performance of procedures (especially observed among general practitioners), which would have been carried out under supervision under normal conditions: “The attending physicians, specialists, the majority of them are absent for fear of contagion and lack of PPE. Resident physicians are often making decisions based on our criteria due to lack of supervision by specialists.” Table 5 contains a summary of comments from the participants.

Table 5

Verbatims from the healthcare workers regarding the work conditions during the outbreak.

In my institution we have no personal protective equipment, we have colleagues infected due to this (18)

It takes 10–12 days to get PCR test results (11)

Testing for all health staff is missing, regardless of direct contact with patient positive for COVID-19 (10)

Transportation, we have no way to get to work (7)

We have no protocols, or we don’t know about them (5)

Lack of cohesion between national and foreign guidelines (4)

Lack of coordination between the healthcare staff. (4)

An obstacle is the anxiety that is being generated in health professionals to provide a service. (4)

They do not give us personal protective equipment to the point that it is necessary to buy it.(3)

There is no education for the general population, they could be a possible source of infection (3)

No follow-up of asymptomatic cases who walk around freely (2)

Misclassification due to continuous changes of protocols. (2)

Healthcare support staff with limited training in this type of infection. (2)

Occupational physicians do not put themselves in our shoes… I was told that young people don’t die from COVID-19 and I had to work until I had symptoms… (2)

We are not a high complexity emergency department and we do not handle mechanical ventilation. I had contact with a patient, and I was tested for COVID-19. (1)

I can notice that the protective equipment supplied is insufficient and we have been buying mostly masks and goggles from our own pockets. The use of alcohol is very limited, they restrict it, which I think is dangerous. I note that the nursing assistants are the most vulnerable to infection, they are not well protected. (1)

Difficult surveillance of patients in rural areas because there are very distant communities and due to the emergency situation, it is difficult to have transportation to access these areas (1)

The numbers in parentheses indicate the number of times the same idea was repeated.

Discussion

This study identified severe PPE shortages, insufficient training regarding infection prevention and PPE usage, and lack of readily available testing and isolation protocols for healthcare workers in Ecuador, Brazil, and Colombia. Owing to this, many healthcare professionals have contracted COVID-19 since the initial outbreak in late 2019 [24]. It is not possible to determine the number of Latin American professionals infected in the course of caring for patients with COVID-19. Particularly, healthcare workers cited difficulties in undergoing PCR tests and the breakdown of the PPE supply chain to be their two biggest concerns. With South America on the brink of a potential second outbreak, health authorities must implement substantial changes to ensure an adequate health system response to the challenge posed by the COVID-19 pandemic.

Approximately three-quarters of the participants felt that they did not have the necessary resources to adequately care for patients with COVID-19. This was most prevalent in workplaces with specialized units (ICUs, hospital wards, or emergency departments), particularly in public hospitals. Although most centers (public and private) had protocols for caring for patients with COVID-19, the majority of the participants reported that they did not know how to implement these protocols or reported that there were significant shortcomings that prevented their implementation.

During an epidemic, the development of infection in healthcare professionals negatively impacts the capacity to treat patients, staff morale [7, 25], and public confidence. Therefore, healthcare professionals must be adequately protected. A recent study reported that appropriate PPE use could reduce the risk of contagion, even during aerosol-generating procedures [14].

In this study, only 2 out of 10 professionals who performed high-risk procedures reported that they had adequate PPE in their workplace. This study also found that the perceived needs of professionals for PPE are not always in line with the real needs for the task at hand. Nearly half of the professionals who did not perform aerosol-generating procedures reported a lack of protective eyewear or special protective suits. This result highlights a lack of dissemination of clear information; with appropriate information, professionals can appease their fears about caring for patients with COVID-19. This study highlights the lack of preparedness among healthcare personnel to protect themselves from possible infection, which could be one of the causes for the increase in the number of infected professionals.

Our results are similar to those reported by the STREPRIC group, who found that less than half of the professionals had received specific training in using PPE in a sample of family doctors in Spain. This lack of training contributes to insecurity and greater psychological distress [13]. This premise can be especially accentuated in intensive care physicians who lack the resources necessary to care for patients with COVID-19 or for self-protection to avoid infection, which can damage morale [26]. In this study, 12.6% of the participants worked in ICUs and 29.9% worked in emergency departments. This group needs to be well protected so that the capacity of treating patients can be maintained throughout the pandemic. This study reports a novel finding: there are a number of professionals who supply their own PPE and/or undergo a PCR test on their own. Up to 3 out of 5 of public health professionals had to undergo a PCR test on their own and had to continue working as long as they did not present with symptoms or obtained the test result. The reasons for this were not analyzed, but this could be due to a lack of resources and the distress of professionals of becoming ill or infecting their loved ones. Future research on this aspect is warranted.

The results obtained in this study differ in some respects from those in other continents, which could be due to differences in the health systems of the participating countries. Furthermore, the economic and social contexts and the health system model in Latin America may explain some of our findings, such as the lack of access to different PPE equipment and diagnostic methods for both professionals and patients.

Globally, a high number of health professionals have been infected with SARS-CoV-2 [27]. This may be due to several factors: the contagion rate at the beginning of the pandemic [28], the lack of protocols and training regarding the efficacious use of PPE [29], and the lack of equipment to protect against the infection risk inherent to healthcare activities [30]. The findings of this study are in agreement with those of others suggesting that the scarcity and reuse of PPE and lack of training may be the cause of the high number of healthcare workers infected worldwide [9]. However, this study shows that the fear of contagion influences professionals’ perception as to what equipment was actually required.

The health emergency resulting from the COVID-19 pandemic took the health systems of Latin American countries and the world by surprise. However, the response must be reviewed to strengthen the supply chain, enhance international collaboration, and establish action plans in conjunction with international organizations to deal with possible future outbreaks and new epidemics. This review must cover training programs, both in terms of basic medical training and specialist training. Furthermore, the training delivered in the epidemiology and public health fields should be reviewed. Healthcare professionals and institutions should examine ways to strengthen the PPE supply chain.

This study has several limitations. First, although the study sample corresponded to different hospital centers in different cities of the participating countries, sampling was non-random. The sample is not completely homogeneous, as there are differences in the proportions of professional groups for each country. Second, information should be collected from professionals with COVID-19 to obtain feedback from a patient perspective; this could provide relevant information for the health system. Third, since this was a cross-sectional study, it is not possible to follow the evolution of and the limitations and requirements faced by frontline professionals. Lastly, no pilot test of the survey was conducted due to the urgent nature of the COVID-19 pandemic.

Healthcare professionals in Latin America may face more difficulties than those from other continents, mainly Europe, Asia, and North America. In particular, access to PCR tests in case of close contact with a person with COVID-19 without appropriate PPE and inadequacies related to diagnosing and treating patients with COVID-19 appear to be significant issues. The availability of PPE is essential for the health system to continue functioning and cope with the pandemic; yet, the general perception of healthcare workers is that they have not been able to access adequate PPE to protect themselves from COVID-19. Healthcare workers must feel protected and be aware of the proper PPE needed in each scenario. If this is not the case, diminished work morale could harm the professional’s resilience to endure the pandemic. Policymakers should ensure access to diagnostic testing and adequate PPE for healthcare workers. Technical and logistical difficulties should be addressed in the event of a future outbreak by learning from our experience with the COVID-19 pandemic. Further studies are needed in subsequent phases of the pandemic to assess and compare the learnings, capacity, and adaptability of the health systems in South America and address any further concerns.

Conclusions

In conclusion, this study sought to identify the main difficulties and obstacles faced by frontline professionals caring for patients with COVID-19 in three Latin American countries. This pandemic has presented unprecedented challenges, and difficulties have been encountered worldwide. Developing countries with economic difficulties face additional challenges in this regard. However, for healthcare professionals to provide adequate care to patients with and without COVID-19 during the pandemic, professionals should feel physically and mentally prepared. It is important for authorities to provide an efficient supply chain, up-to-date protocols, and clear information. Our study has highlighted some areas that need to be improved for dealing with further waves of the COVID-19 outbreak and potential future pandemics and epidemics.

Survey conducted in the study.

Anonymous survey administered to the participants.

(DOCX)

Click here for additional data file.

Resources for appropriate diagnosis and treatment of COVID-19 patients in several settings.

(DOCX)

Click here for additional data file.

Unavailability of personal protective equipment as reported by each professional group.

(DOCX)

Click here for additional data file.

10 Sep 2020

PONE-D-20-25186

Personal protective equipment, diagnostic and treatments facilities for COVID-19 patients. A cross-sectional study in Brazil, Colombia and Ecuador.

PLOS ONE

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A copy of your manuscript showing your changes by either highlighting them or using track changes (uploaded as a *supporting information* file)

A clean copy of the edited manuscript (uploaded as the new *manuscript* file)

4.

We note that you have indicated that data from this study are available upon request. PLOS only allows data to be available upon request if there are legal or ethical restrictions on sharing data publicly. For information on unacceptable data access restrictions, please see http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions.

In your revised cover letter, please address the following prompts:

a) If there are ethical or legal restrictions on sharing a de-identified data set, please explain them in detail (e.g., data contain potentially identifying or sensitive patient information) and who has imposed them (e.g., an ethics committee). Please also provide contact information for a data access committee, ethics committee, or other institutional body to which data requests may be sent.

b) If there are no restrictions, please upload the minimal anonymized data set necessary to replicate your study findings as either Supporting Information files or to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. Please see http://www.bmj.com/content/340/bmj.c181.long for guidelines on how to de-identify and prepare clinical data for publication. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories.

We will update your Data Availability statement on your behalf to reflect the information you provide.

5. Please amend your authorship list in your manuscript file to include author Stefany Pacheco

6. Please amend the manuscript submission data (via Edit Submission) to include author Gloria Pacheco

Additional Editor Comments (if provided):

English language correction by the well-recognized editing service is deemed necessary.

Methodological weaknesses as pointed out by the reviewer should be taken into account to strengthen scientific rigour.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: No

Reviewer #2: Yes

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: No

Reviewer #2: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: This is a survey of healthcare workers (HCW) in South America aimed at evaluating PPE shortages and related issues arising from the COVID-19 pandemic. It is true that such data from South America is scarce, and as such, an important gap is being addressed by the authors. I commend them on this tremendous effort in the midst of a raging pandemic and wish them well.

I have listed some major and minor points for consideration by the authors. Overall, there is some unique data presented here, and I believe it would be of significant interest to the healthcare community in Latin America and globally.

The methodology is appropriate for a pandemic, but does have some limitations that should be clearly articulated. Overall, the methods section needs to be clearer and reported according to one of the many published checklists or guidelines (I have provided citations below, but the authors may choose to use something else).

I do not believe it is appropriate or desirable to report inferential statistics with this survey. Descriptive statistics with a focus on the shortcomings in the pandemic response (PPE availability, lack of education, lack of COVID-19 testing for HCWs) would be my recommendation.

Specific points listed below.

Major

1.I fully understand that English may not be the first language for all or most of the authors. Respectfully, the grammar and general usage of the English language throughout this manuscript must be improved prior to consideration for publication. I have pointed out a small sample of these in the Minor comments to assist you in identifying areas for improvement.

2.Methods:

- Please provide a more detailed methodology section. There are lots of items missing. I recommend the use of a tool such as described in this paper by the ACCADEMY group: A guide for the design and conduct of self-administered surveys of clinicians. Karen E.A. Burns, Mark Duffett, Michelle E. Kho, Maureen O. Meade, Neill K.J. Adhikari, Tasnim Sinuff, Deborah J. Cook. CMAJ Jul 2008, 179 (3) 245-252; DOI: 10.1503/cmaj.080372

- there is a nice checklist in this paper that may also be useful: Artino AR Jr, Durning SJ, Sklar DP. Guidelines for Reporting Survey-Based Research Submitted to Academic Medicine. Acad Med. 2018;93(3):337-340. doi:10.1097/ACM.0000000000002094

- it is acceptable to clearly state this is a survey conducted by non-random, snowball sampling and internal pilot testing without a fully validated survey tool (appropriate given the urgency of the pandemic)

3.Results:

- The columns in each of the tables are different. Please pick one categorisation and stick to it. Where necessary, the other categorisations may be used in the text and listed in the appendix.

- My preference would be for predominant reporting of descriptive statistics without an emphasis on inference. This survey is simply not designed to answer any inferential questions, though it is very tempting to calculate p values when you have a reasonably large dataset.

4.Free text comments

- please consider listing more of the free text comments in a separate Table- these are very powerful and in my opinion, some of the most important findings from your survey. Please use this platform to help colleagues without a voice be heard.

5.Discussion:

- the first paragraph of the discussion should list all the key findings from the study, rather than re-state the aim which has already been done. I would say that the severe PPE shortages, lack of readily available testing and preventative isolation for HCWs and inadequacy of PPE and infection prevention training for HCWs.

- I would also add a “Conclusions” paragraph at the end of the Discussion which again stresses the key messages from the survey and one or two key learning points or future directions.

- please emphasise the need for governments and policymakers to be aware of this sort of data and for professionals bodies to agitate for change.

Minor

1.When reporting large numbers, please use commas as separators for every 3 places (e.g. 1,000,000).

2.P9 L 59- remove today and just state the date on which the numbers were updated.

3.P9 L 68- “outpointed” is used incorrectly. Please change to “demonstrated”

4.P10 L95- Please state a primary objective and one or more secondary objectives

5.P11 L107- “telematic” is not a recognised word- I would suggest “teleconferencing”.

6.P12 L143-145- I understand that due to the language the WHO has been using, you have chosen to separate the groups based on aerosol generating procedures- however, there is increase evidence that simple things like breathing and talking are aerosol generating, and that the aerosol/droplet dichotomy is an oversimplification. Some acknowledgement of this would be appropriate, even if you don’t change your actual methods.

7.P13 L147-153- What surveying software was used? Google forms, Survey Monkey etc

Was the number of participants you wanted to recruit prospectively determined?

Your sampling technique is non-random (which you have mentioned in the abstract but not in the Methods section). In this setting, statistical significance has limited meaning. I would suggest you state that you wanted a large enough sample to be able to make some generalisations, rather than for the sole purpose of generating small enough p values.

8.Table 5- currently not very clear as to what the table is reporting. I’m assuming that the percentages are for equipment that respondents are reporting as unavailable.

Reviewer #2: The author(s) choose appropriate web based data collection method and inclusion of qualitative portion can add more information. The study consist appropriate categories of health professional and consist both public and private setting. But weak in statistical analysis.

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Dr Mahesh Ramanan

Reviewer #2: Yes: Dr Hla Hla Win

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

8 Oct 2020

Dear Editor,

We appreciate very much the work done by the reviewers, particularly in this period we assume that is an additional effort as we are well aware of the difficulties arising from the COVID outbreak. Many thanks. Also, we appreciate the suggestions. We are sure they improve this work. We have followed your directions and included a manuscript with tracked changes, and a revised manuscript. In this letter, we comment one by one on these suggestions.

Yours faithfully

The authors

Editorial comments:

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming.

We have revised the manuscript in order to meet PLOS One style requirements.

2. Please provide further details on sample size and power calculations. Please provide approximate numbers of health workers (especially doctors and nurses) and treatment facilities for COVID-19 in the 3 countries. Please discuss whether your sample size would be sufficiently representative of your target population.

Further details and information from national and international official statistics sources have been added, and a comment made in the methods section.

3. We suggest you thoroughly copyedit your manuscript for language usage, spelling, and grammar. If you do not know anyone who can help you do this, you may wish to consider employing a professional scientific editing service.

Attached you´ll find Editage certificate. Thank you for the advice provided.

4. We note that you have indicated that data from this study are available upon request.

We have uploaded our data set in an open access file repository:

Mira JJ. PPE, diagnostic and treatment facilities for COVID-19 in South America 2020. doi:10.17605/OSF.IO/4EG8R.

Also, the study is publicly available at ClinicalTrials: NCT04486404

5. Please amend your authorship list in your manuscript file to include author Stefany Pacheco

We have amended our authorship list via the Edit Submission and included author Gloria Pacheco.

Reviewer comments:

1. Please provide a more detailed methodology section. There are lots of items missing.

We have followed the ACCADEMY group guideline for design and conduct of self-administered surveys of clinicians, and we appreciate the advice given by the reviewer. We have made the necessary corrections and provided a more detailed methods section.

2. The columns in each of the tables are different. Please pick one categorisation and stick to it. Where necessary, the other categorisations may be used in the text and listed in the appendix.

We have taken under consideration reviewer advice and included two of the original tables as a supplementary file to be available online. More precisely, former Table 2 and 4. We acknowledge, that having different columns to display information may be confusing but we consider this to be necessary as relevant information is provided. We consider that tables comparing public and private resources available to healthcare workers, differences of Personal Protective Equipment at disposal of healthcare workers who performed high risk of contagion procedures and finally, training for correct use of PPE and use of protocols for healthcare workers to be important, as they align with the recommendations made to managers and policy makers.

3. My preference would be for predominant reporting of descriptive statistics without an emphasis on inference. This survey is simply not designed to answer any inferential questions, though it is very tempting to calculate p values when you have a reasonably large dataset.

We agree with the reviewer and we have made changes to our methods section. Even though we have decided to keep Chi Square analysis in some categories, this could be removed if editorial and reviewers consider it necessary.

4. Please consider listing more of the free text comments in a separate Table- these are very powerful and in my opinion, some of the most important findings from your survey. Please use this platform to help colleagues without a voice be heard.

We cannot agree more with you, relevant information was provided by means of the free text comments, we received a total of 365. We have included Table 5, which lists more extracts and the number of times a similar idea was expressed by respondents.

5. the first paragraph of the discussion should list all the key findings from the study, rather than re-state the aim which has already been done. I would say that the severe PPE shortages, lack of readily available testing and preventative isolation for HCWs and inadequacy of PPE and infection prevention training for HCWs.

We have made the necessary corrections and included key findings in the first paragraph of the discussion.

6. I would also add a “Conclusions” paragraph at the end of the Discussion which again stresses the key messages from the survey and one or two key learning points or future directions.

A “conclusion” paragraph was added at the end of the discussion and also key points for managers and policy makers were included. Hopefully this research can provide feedback and future directions for governments in South America.

7. I understand that due to the language the WHO has been using, you have chosen to separate the groups based on aerosol generating procedures- however, there is increase evidence that simple things like breathing and talking are aerosol generating, and that the aerosol/droplet dichotomy is an oversimplification. Some acknowledgement of this would be appropriate, even if you don’t change your actual methods.

We recognize this dichotomy could be an oversimplification, but we can also agree on that some procedures poses an inherent risk that could only be performed in safe spaces of a hospital. This is why we have included the following phrase in our methods section “This distribution was done considering the increased risk of infection associated with some COVID-19 patient care practices as opposed to others, which normally advise differentiated personal protective equipment needs.” Which is also why, we have considered as important to preserve the table comparing both circumstances, where protocols differ as which PPE are necessary for each of them. We believe, it is also important to communicate how this increased perception of higher risk and exposure of HCW (reported by other studies) can modify their demands. One example of this, is how 60% of participants who do not perform high risk procedures reported as unavailable special protected closed suits, when it is not necessary, according to current protocols.

Minor comments

We have made the necessary corrections and copyedited our manuscript using Editage services.

We have included two objectives in the last paragraph of the introduction.

We have included details about Surveymonkey as the platform used to conduct the study.

More details about the sample and its size has been added to the methods.

Submitted filename: Response to Reviewers.docx

Click here for additional data file.

14 Oct 2020

PONE-D-20-25186R1

Personal protective equipment, diagnostic and treatments facilities for COVID-19 patients. A cross-sectional study in Brazil, Colombia and Ecuador.

PLOS ONE

Dear Dr. Martin-Delgado,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

We look forward to receiving your revised manuscript.

Kind regards,

Khin Thet Wai, MBBS, MPH, MA (Population & Family Planning Resear

Academic Editor

PLOS ONE

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Thank you for addressing my comments and congratulations on an important piece of work.

I have a small number of minor revisions that I recommend:

L40: change “it was not randomized” to “sampling was non-random”

L56-59: update COVID case numbers and deaths from latest WHO Sitrep

L153: change “It was prepared using…” to “We used..” for simplicity

Table 3, L212: “Did not performed” should read “Did not perform”

Discussion

L272-273: The first two sentences do not belong here. They should either be deleted or moved later into the discussion. I think you should start with your major findings i.e. “This study has identified severe PPE shortages, insufficient training in infection prevention and PPE usage, and lack of readily available testing and isolation protocols for healthcare workers in Ecuador, Brazil and Colombia…..”

L346: “sampling was non-random”

L375: drop this sentence “Otherwise, responsiveness is questioned”.

L376: “Our study has highlighted some areas that need to be improved **for further waves of COVID-19 and potential future pandemics and epidemics**.”

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Mahesh Ramanan

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

15 Oct 2020

Dear Editor,

We appreciate very much the work done by the reviewer, particularly in this period we assume that is an additional effort as we are well aware of the difficulties arising from the COVID outbreak. Many thanks. Also, we appreciate the suggestions. We are sure they improve this work. We have followed your directions and included a manuscript with tracked changes, and a revised manuscript. In this letter, we comment one by one on these suggestions.

Yours faithfully

The authors

Reviewer comments:

Minor comments

L40: change “it was not randomized” to “sampling was non-random”

We have unified the term to “non-random” across the manuscript.

L56-59: update COVID case numbers and deaths from latest WHO Sitrep

We have updated COVID cases and deaths according to WHO Dashboard, and changed the citation.

L153: change “It was prepared using…” to “We used..” for simplicity

We have included your suggestion. We agree, on simplicity.

Table 3, L212: “Did not performed” should read “Did not perform”

We have corrected the table.

Discussion

L272-273: The first two sentences do not belong here. They should either be deleted or moved later into the discussion. I think you should start with your major findings i.e. “This study has identified severe PPE shortages, insufficient training in infection prevention and PPE usage, and lack of readily available testing and isolation protocols for healthcare workers in Ecuador, Brazil and Colombia…..”

We have modified the first paragraph of the Discussion. Thank you for your advice.

L375: drop this sentence “Otherwise, responsiveness is questioned”.

The sentence has been removed.

L376: “Our study has highlighted some areas that need to be improved **for further waves of COVID-19 and potential future pandemics and epidemics**.”

We have included reviewer suggestion.

Submitted filename: Response to Reviewers.docx

Click here for additional data file.

19 Oct 2020

PONE-D-20-25186R2

Personal protective equipment, diagnostic and treatments facilities for COVID-19 patients. A cross-sectional study in Brazil, Colombia and Ecuador.

PLOS ONE

Dear Dr. Martin-Delgado,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

We look forward to receiving your revised manuscript.

Kind regards,

Khin Thet Wai, MBBS, MPH, MA (Population & Family Planning Resear

Academic Editor

PLOS ONE

Additional Editor Comments (if provided):

To correct minor grammatical errors throughout the manuscript.

[Note: HTML markup is below. Please do not edit.]

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

26 Oct 2020

Dear Editor,

We appreciate very much the work done by the reviewers and editorial office, particularly in this period we assume that is an additional effort as we are well aware of the difficulties arising from the COVID outbreak. Many thanks. Also, we appreciate the suggestions. We are sure they improve this work. We have followed your directions and included a manuscript with tracked changes, and a revised manuscript. In this letter, we comment one by one on these suggestions.

Yours faithfully

The authors

Reviewer comments:

Minor comments

To correct minor grammatical errors throughout the manuscript.

We have provided a new version that has been copyedited by Editage and supplied the certificate of editing.

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool.

We have followed PLOS ONE requirements and used PACE to ensure that.

Submitted filename: Response to Reviewers.docx

Click here for additional data file.

29 Oct 2020

Availability of personal protective equipment and diagnostic and treatment facilities for healthcare workers involved in COVID-19 care: A cross-sectional study in Brazil, Colombia, and Ecuador.

PONE-D-20-25186R3

Dear Dr. Martin-Delgado,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Khin Thet Wai, MBBS, MPH, MA (Population & Family Planning Resear

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

All requirements inclusive of language correction have been fully addressed.

Reviewers' comments:

3 Nov 2020

PONE-D-20-25186R3

Availability of personal protective equipment and diagnostic and treatment facilities for healthcare workers involved in COVID-19 care: A cross-sectional study in Brazil, Colombia, and Ecuador

Dear Dr. Martin-Delgado:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Khin Thet Wai

Academic Editor

PLOS ONE