A commentary on

Verbeek J H, Rajamaki B, Ijaz S et al.

Personal protective equipment for preventing highly infectious diseases due to exposure to contaminated body fluids in healthcare staff. Cochrane Database Syst Rev 2020; 4: CD011621. DOI: 10.1002/14651,858.CD011621.pub4.

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GRADE rating


The Cochrane systematic review and meta-analysis by Verbeek et al. (2020) comprehensively evaluated the effectiveness of different types of personal protective equipment (PPE) in reducing the risk of infection transmission among healthcare workers due to exposure to contaminated body fluids.1 In the midst of COVID-19 pandemic, this review provides timely and critical evidence to healthcare professionals on reducing transmission of infection in healthcare settings.

The World Health Organisation declared the COVID-19 outbreak as a public health emergency of international concern on 30 January 2020 and subsequently a global pandemic on 11 March 2020. Currently, there is no effective vaccine against COVID-19, and disease countermeasures mainly rely on preventing or slowing person-to-person transmission.2 Studies acknowledge the need to consider regional epidemic characteristics such as the prevalence of COVID-19 cases and trend of the epidemic curve when determining the level of PPE required within specific healthcare settings.3

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The WHO guideline for 'infection prevention and control of pandemic respiratory infections in healthcare' recommends using appropriate types of PPE based on risk assessment, determined by the nature of procedure and suspected pathogen.4,5 Consequently, the type of PPE worn by HCWs is critical in reducing transmission of infection in healthcare settings, particularly when aerosol-generating medical or dental procedures are being performed.3 The potential for aerosol spread of the virus through dental procedures, such as use of high and low-speed handpieces, ultra-sonic scalers, air/water syringes, intra-oral radiographs or an infected patient coughing, places dental HCWs at an elevated risk of infection.6 Due to the unique characteristics of dental procedures where a large number of droplets and aerosols could be generated, the standard protective measures employed in routine clinical work may not be sufficient to prevent the spread of COVID-19, especially when patients are in the incubation period and unaware of their infections status.7

Up until now, there has been no universal guidelines for dental care provision during the time of epidemics, pandemics and national disaster.7 Pandemic planning for dental services has typically involved a step-down process, with cancellation of routine care first, then urgent care, followed by the provision of solely emergency care.6 Across the globe, dental settings have prioritised urgent and emergency care and suspended elective visits and procedures to protect HCWs and patients, preserve PPE supplies and expand available hospital capacity.6,7 However, mounting demand for PPE driven not only by number of COVID-19 cases but also by misinformation, panic buying, and stockpiling has resulted in shortages of PPE globally for the HCW.5,8

A coordinated set of PPE standards and a unified design for PPE are required to protect HCW when taking care of patients with highly infectious diseases.1 Studies point out that PPE scarcity could be mitigated to an extent through identification of effective reprocessing, extended use and re-use techniques.8 Evidence indicates that respirators maintain their protection when used for extended periods.9 However, using a respirator for longer than four hours should be avoided as it can lead to discomfort.9,10 Although studies have acknowledged that extended PPE use during times of severe shortages could reduce the utilisation rate,1,8,11 the safety of such techniques in containing the infection transmission has not been extensively researched in practical settings. During previous public health emergencies involving acute respiratory illnesses, respirators such as N95, FFP2 or equivalent standard have been successfully used for extended time.11 This entailed wearing the same respirator for multiple patients with the same diagnosis without removing it.1,8 Reprocessing PPE must consider material composition, functionality post treatment, along with appropriate disinfection.2 There is scant published literature on efficacy of reprocessing PPE.

The unprecedented pandemic situation and increased PPE burn rate has created a space for healthcare digital innovation. Telemedicine and teledentistry has become part of the care delivery process in many parts of the world, thereby minimising the need for PPE use and need for people to go to healthcare facilities to seek care. A recently updated Cochrane systematic review on the effects of interactive telemedicine on professional practice and healthcare outcomes using 93 eligible trials and over 22,000 participants concluded that interactive telemedicine can lead to similar health outcomes as face-to-face delivery of care.12

Several studies including guidance, based on clinical and epidemiological data, have highlighted the need for coordinated efforts to prevent and reduce transmission of infection to HCWs.2,8,11,13 In response to the lack of evidence and appropriate PPE guidance within dentistry, in many countries, healthcare quality and safety control centres including professional associations have put forward their recommendations for dental services during the COVID-19 outbreak. Concurrently, rapid reviews have been conducted to enable policy makers to develop comprehensive national guidance for dentistry.6 The majority of the studies included in the existing rapid reviews lack underpinning evidence and some areas are unlikely to ever have strong (or any) research evidence.6 Research is urgently required to build evidence on what types of PPE, and which modifications provide most appropriate, manageable protection for members of the dental team to deliver care safely.