The experience of loneliness seems to be a common theme interconnecting almost every account from frontline health staff working at the hospital, local health services and assisted nursing homes. The factor that probably contributed the most to this sense of abandonment was staff feeling unprotected, which nullified- perception wise- the many other significant measures introduced by management. On 29 May, data on health workers recorded 28,000 infected (a good 12% of the total) and more than 200 dead.
The operators report that aside from not feeling safeguarded they were also the target of a form of collective fury, like a “race to the bottom” to avoid protecting them. Given the trend of the infection curve it would actually be wrong to link this disaster solely to the initial shortage of facemasks or to the broken promises of the Italian civil protection.
The weaknesses of protocols
The protocols of the World Health Organisation (WHO) and the National Institute of Health (ISS) clearly recommended insufficient protection levels for staff. Moreover, the regions, the ASLs (or local health authorities) and the hospitals challenged the protocols too late.
The WHO revised its protocol on 6 April [1], essentially leaving everything unchanged compared to the previous one released on 19 March, despite numerous reports from different countries and the scientific community trying to take action around the subject [2-3]. The protocol of the WHO confirmed 2 points: the disease could only spread through droplets (or aerosol when using invasive procedures) and asymptomatic subjects were lowly infectious. However, authoritative studies already gave contrasting data on both points [4-7].
The first safeguarding protocol of the ISS, which was the same protocol of the WHO, was revised on 28 March [8] with the addition of a few amendments. However, it considered very marginally the requests of the trade unions and of some independent organisations like the Gimbe Foundation [9], and it ignored the protocols of the European Centre for Disease Prevention and Control [10] and the Centres for Disease Control and Prevention [11], which offered a better level of protection. A further revision will be taking place on 10 May with a few variations. The ISS document does not advise the systematic use of FFP2 masks in all situations involving the assistance of Covid 19 patients (there are various possible scenarios). It advises staff to only use surgical masks in the hospital triage areas, whereas no protection (not even surgical facemasks) is planned for non-Covid wards.
All of this seemed absolutely incomprehensible to the frontline health staff, as they witnessed numerous hospital epidemics (many of which originated from non-Covid wards or from asymptomatic cases) and saw too many colleagues getting infected and some of them dying; not to mention the elderly homes, the GPs and finally the infected relatives. Unfortunately the hypothesis that the positive asymptomatic subjects were few and lowly infectious persisted beyond any reasonable limit, despite the prompt research of Professor Crisanti in Vo’ and some Chinese physicians already raising the alarm [4].
After months of debates and battles around the use of personal protection equipment and particularly masks, perhaps the reason for the misalignment between the institutional and professional bodies was the following: on one end the WHO and the ISS were trying to base their indications on solid trials and/or systematic reviews, while on the other end was the outcry of workers, “We are getting infected and we are dying, isn’t this enough evidence for you to accept that the level of protection that you recommend is wrong?”
The scientific approach would actually be enough. In fact, according to the “falsification principle” proposed by the philosopher Popper a single piece of evidence that contradicts a theory is enough to disprove it. Given the results one can therefore state that whichever was the theoretical basis of the protocols of the WHO and ISS this was incorrect.
A cautious approach
Regarding the protection of staff it would have been more helpful to adopt a pragmatic tactic such is the “parachute approach” [12], whereby even without any supportive trial data nobody would jump from a plane without one. In the absence of certainty it would have been cautious to start with a high level of protection rather than the other way around. The past coronavirus epidemics (SARS and MERS) attest to this, because the cost of human life paid by the health staff has been very high and partly avoidable.
Even though the initial protection level was low the fact that the standards were not rapidly increased seems incomprehensible given that the safety regulations sector typically follows an empirical-inductive approach. According to this method the protection levels would be increased based on individual incidents from which regulations and universal methods are drawn in order to avoid these happening again; an example is aviation.
In the healthcare sector the reactive approach of clinical risk management foresees just this. When an avoidable adverse event takes place the root causes are analysed to try and understand what triggered it, then immediate action is taken to reduce that risk in the future. That is why it is so difficult to understand the sluggishness that, despite repeated incidents happening (infected staff, infected patients/visitors and infected family members), led to the prolonged suboptimal protection of staff, which was the root cause of those incidents.
As an hygiene specialist I am sorry to admit that this sluggishness belonged to too many medical directors, hospital directors, risk managers of regions and companies, occupational doctors and prevention and protection service managers, who didn’t act expeditiously to make the relevant adjustments despite the countless incident reports.
The consequence of this dramatic situation involving the infection and death of health workers was that the Government attempted to waive the liability of the higher management levels around the infection spread and the deaths among staff [13]. This certainly reconfirmed the general sense of abandonment staff described.
They did not act expeditiously to make the relevant adjustments despite the countless incident reports.
References
[1] WHO. Rational use of personal protective equipment for coronavirus disease (covid-19) and considerations during severe shortages.
[2] Godlee F. Protect our healthcare workers. BMJ 2020;369:m1324.
[3] Covid-19: protecting health-care workers. Lancet 2020;395:921-1010.
[4] Chang D, Xu H, Rebaza A, et al. Protecting health-care workers from subclinical coronavirus infection. Lancet Respir Med 2020;8:e13.
[5] National research council 2020. Rapid expert consultation on the possibility of bio-aerosol spread of sars-cov-2 for the covid-19 pandemic. Washington, DC: The National Academies Press, 2020.
[6] Li R, Pei S, Chen B, et al. Substantial undocumented infection facilitates the rapid dissemination of novel coronavirus. Science 2020:368:489-93.
[7] van Doremalen F, Bushmaker T, Morris DH, et al. Aerosol and surface stability of sars-cov-2 as compared with sars-cov-1. N Engl J Med 2020;382:1564-7.
[8] ISS. Indicazioni ad interim per un utilizzo razionale delle protezioni per infezione da sars-cov-2 nelle attività sanitarie e sociosanitarie (assistenza a soggetti affetti da covid-19) nell’attuale scenario emergenziale sars-cov-2.
[9] Gimbe. Proposta di modifiche al documento Rapporto Iss Covid-19 n. 2/2020. 23 March 2020.
[10] Ecdc. Personal protective equipment needs in healthcare settings for the care of patients with suspected or confirmed novel coronavirus (2019-nCoV).
[11] Cdc. Interim infection prevention and control recommendations for patients with suspected or confirmed coronavirus disease 2019 (covid-19) in healthcare settings.
[12] Potts M, Prata N, Walsh J, et al. Parachute approach to evidence based medicine. BMJ 2006;333:701.
[13] Beux A. Coronavirus: non si può annullare la responsabilità di politici e amministratori. Quotidiano Sanità, 4 April 2020.
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