Journal of Medical Society

ORIGINAL ARTICLE
Year
: 2022  |  Volume : 36  |  Issue : 1  |  Page : 11--17

Doctors with skin injuries due to personal protective equipment in a dedicated COVID-19 hospital: A descriptive study from tribal India


Vikas Gupta1, Prem Singh Nayyer2, Vinita Gupta3, Rajesh Ranjan4,  
1 Assistant Professor, Department of Community Medicine, Birsa Munda Government Medical College and Hospital, Shahdol, Madhya Pradesh, India
2 Consultant, Department of Internal Medicine, Dr. Baba Sahib Ambedkar Medical College and Hospital, Rohini, Delhi, India
3 Senior Specialist, Department of Obstetrics and Gynecology, Dr. Baba Sahib Ambedkar Medical College and Hospital, Rohini, Delhi, India
4 Professor, Department of Community Medicine, NIMS, Noida, Uttar Pradesh, India

Correspondence Address:
Dr. Vikas Gupta
Department of Community Medicine, Government Medical College, Shahdol, Madhya Pradesh
India

Abstract

Background: With the emergence of highly infectious epidemics/pandemics, such as Ebola virus diseases, severe acute respiratory syndrome, and coronavirus disease-2019 (COVID-19), doctors are at much greater risk of infection due to the exposure to the highly infectious bodily fluids and droplet nuclei. Hence, treating and caring for patients need the use of personal protective equipment (PPE) to reduce the transmission risk. Objectives: The present study was conducted to estimate the prevalence of skin injury and its type due to PPE usage, to find the association of related factors with the skin injuries among doctors. Materials and Methods: This descriptive cross-sectional study was conducted after obtaining the institutional ethical approval in dedicated COVID-19 hospital for a period of 4 months among 132 doctors wearing grades 2 and 3 PPE kit using a questionnaire collecting the details regarding baseline, duty, skin injury characterization. During analysis of data, an association between variables was significant for P < 0.05. Results: It was observed that 17.1% of doctors were wearing the PPE kit for 5 or more hours/and 13.0% of subjects reported absenteeism from duty hours due to PPE-induced skin injuries. 76.4% of subjects have suffered from skin injury after PPE usage. The most common symptoms/signs for the skin injury occurred was indentation and pain on back of ears (61.0%). Conclusion: The skin injuries of PPE among the doctors may result in reduced morale for overloaded work and made them anxious. Hence, an appropriate monitoring of these adverse effects should be done and effective preventive measures should be adopted.



How to cite this article:
Gupta V, Nayyer PS, Gupta V, Ranjan R. Doctors with skin injuries due to personal protective equipment in a dedicated COVID-19 hospital: A descriptive study from tribal India.J Med Soc 2022;36:11-17


How to cite this URL:
Gupta V, Nayyer PS, Gupta V, Ranjan R. Doctors with skin injuries due to personal protective equipment in a dedicated COVID-19 hospital: A descriptive study from tribal India. J Med Soc [serial online] 2022 [cited 2022 Sep 27 ];36:11-17
Available from: https://www.jmedsoc.org/text.asp?2022/36/1/11/355573


Full Text



 Introduction



Personal protective equipment (PPE) refers to equipment used to avoid or reduce the accidental injuries and occupational hazards at work, and they are meant to protect against the physical, chemical, and biological factors encountered in the work environment. With the emergence of highly infectious epidemics, such as Ebola virus diseases and severe acute respiratory syndrome, doctors are at much greater risk of infection than the general population, due to the exposure to the highly infectious bodily fluids and droplet nuclei in the immediate patient environment. Hence, treating and caring for such patients need the contact precautions by means of PPE to reduce the transmission risk.[1],[2]

The use of these protective equipment has again gained the attention among the health-care workers during the global public health emergency due to the coronavirus disease-2019 (COVID-19) appeared in December 2019. Doctors are highly at risk of contracting COVID-19 while caring for the patients, as they have prolonged duration of exposure performing many care interventions including aerosol-generating procedures.[3] Furthermore, there is a common concern of infecting family and friends among doctors. Due to perceived risk of being infected, the doctors generally restrict their social contacts. Even there is feeling of being isolated by their family members and friends among doctors because of their hospital work and which in turn pressurizes them to be absent from work.[4]

Based on the precautionary protocols adopted by various agencies in controlling the infection, adequate use of PPE is reasonable based on the evidence, especially when aerosol-generating medical procedures are being performed.[5] It is shown in literatures that the health-care workers who used mask, gown, and hand washing had less likely developed infection than who did not use them.[6]

Since the mode of transmission of the disease is established to be respiratory droplet and indirect contact with fomites, the use of the PPEs is essential to prevent the cross-transmission of the infection. The PPEs comprise the equipment that protect the mouth, nose, eyes, ears, bare skin, and vulnerable parts, such as head and hands from the deadliest infectious secretions from the patients. Several skin damages have been reported due to PPE, such as pressure injury, contact dermatitis, pressure urticaria, and exacerbation of preexisting skin diseases, including seborrheic dermatitis and acne.[7],[8]

The present institution was started 3 years back and process of recruitment of doctors is ongoing. The number of doctors ranged between 130 and 140. The college being in evolving phase has no postgraduate students and interns, so doctors alone have to look after the patients in the COVID-19 wards besides nurses. Being limited number of doctors, the duties are less rotated and this makes more hours of working for providing clinical care to the patients and more hours of wearing of PPE kit while providing care to the patients. The documented skin injuries due to PPE kit include device-related pressure injury, moisture-associated skin damage, and skin tears are mostly for the patients, and no report of skin injuries among doctors wearing PPE has been seen, which needed to be addressed urgently, so we planned to conduct a descriptive study to estimate the prevalence of skin injury and its type, to find the association of related factors with the skin injuries and to analyze the problems in the prevention and treatment of skin injuries among doctors during the COVID-19 pandemic, which will provide a basis for developing strategies for preventing and treating the skin injuries in upcoming third wave of pandemic.

 Materials and Methods



Study setting and design

This descriptive cross-sectional study was conducted in dedicated COVID-19 hospital (DCH) at Government Medical College, Shahdol, Madhya Pradesh, for a period of 4 months (March 2021 to June 2021). GMC Shahdol was recognized official site as DCH for managing COVID-19 patients on March 27, 2020, when the disease started to occur in epidemic proportion in India.

Study population and sample size

The study subjects were medical doctors currently working at DCH, Shahdol, at the time of the study. The list of the study subjects was obtained from Medical Superintendent office along with their contact details (e-mail and phone) and which counted to 132 eligible subjects.

The sample size was calculated (n = 97) considering the proportion of doctors having PPE-related skin damages as 50% (studies not found in Madhya Pradesh) with confidence level of 95% and 10% absolute allowable error by applying the following formula: n = (Z1 − a/2) 2 × p (1 − p)/d2; where Z = Standard normal variate for level of significance (at 5% type I error [P < 0.05], Z = 1.96 for 2-sided test), a = Level of significance (0.05), p = Prevalence (proportion-50%), d = Absolute allowable error (10%), n = sample size, so all eligible study participants which counted to be 132 were included in the study using convenient sampling method.

Study subject inclusion criteria were as follows: (1) those doctors who cared for the suspicious and positive COVID-19 cases in intensive care unit (ICU), high dependency units, general wards, isolation wards, and private wards with moderate-to-severe risk exposure and were wearing surgical masks with goggles or protective face masks and protective gowns (called as grade 2 PPE) or were wearing N95/KN95 respirators with goggles or protective face masks, protective gowns, latex gloves, and shoes (known as grade 3 PPE); (2) age ≥18 years, regardless of gender; (3) voluntary participants.

Doctors who did not wear PPE or who did not contact the suspicious or confirmed COVID-19 patients were excluded from the study.

Study tool

We designed a survey questionnaire according to relevant guides, research literature,[9],[10],[11] and reviewed and revised three times by consulting dermatologist, statistical experts, doctor in-charges, and feedback was also taken from some nursing staff posted in DCH, Shahdol. It gathered general data (age, gender, designation, marital status, having children in home, staying alone at current place); PPE data (confidence in self-protection for COVID-19, How many days in a week you wear PPE kit, duration of PPE wearing while caring for patients); work absenteeism due to skin injuries; skin reaction related to Mask (Surgical/N95), goggles/face shields, latex gloves (powdered/nonpowdered) and protective clothing; preventive measures taken to avoid skin injuries due to PPE; and treatment sought for the skin injury occurred.

Data collection

Participation in this survey was voluntary and was not compensated. After obtaining approval to conduct this study from the Institutional Ethics and Review Board (IERB), study subjects were approached and recruited through social networking websites (Facebook, Twitter, and Whatsapp) and the password-protected survey links containing Google forms were posted on the same which also included the contact details of the dermatologist (investigator).[12] An introductory paragraph outlining the aims and objectives of the study as well as instructions to complete the questionnaire was explained in the survey link, especially mentioning that if any of doctors having any kind of PPE-related skin injuries at present please visit the dermatologist in the outpatient department hours or consult for any queries during suitable hours over the phone. All questions were mandatory. Informed consent was obtained from each subject before participation. Sufficient time was given to subjects to read, comprehend, and answer all the questions and the subjects could not change the answers after submission of questionnaire. The subjects were given a week's time to voluntarily complete the questionnaire and those who did not responded back to the questionnaire with in defined time after three or more consecutive reminders were declared as nonrespondents and were excluded from the study. The questionnaire was checked for completeness by investigator himself and incomplete questionnaires were excluded from the study. The subjects having skin injuries at present were examined by dermatologist for the site, symptoms, signs, systematic features for skin injury and treatment were prescribed to them. The information pertaining to subjects was kept anonymous and confidential. The study was performed following the Checklist for Reporting Results of Internet E-Surveys guidelines.

Data analysis

Collected data was entered in the MS Excel spreadsheet, was coded appropriately, and was later cleaned for any possible errors. Analysis was carried out using IBM SPSS Statistics for Windows, Version 22.0 (IBM Corp. Armonk, NY, USA). During data cleaning, to facilitate association of variables, more variables were created. Clear values for various outcomes were determined before running frequency tests. Categorical data were presented as percentages (%) and quantitative data was presented as mean (standard deviation). The baseline and duty-related characteristics were considered as the independent variables and presence of skin injuries was considered as the dependent variable. Chi-square analysis was used to find the association between dependent and independent variables. All tests (two tailed) were performed at a 5% level of significance; thus, an association was significant if P < 0.05.

Ethical consideration

All ethical issues were followed during the study. Participation was voluntary and participants were allowed to withdraw from study at any moment. No personal data was recorded. Participants were assured that all data collected was used only for the current study. Study was initiated after approval from IERB (Project ID: IERC/21/07/001). In addition, before filling the questionnaire, participants were asked to give their consent to participate in the study.

 Results



Out of total 132 study subjects, 123 subjects provided their responses for the questionnaire sent over social media. The mean age of study subjects was 32.8 ± 6.2 years. More than half of the study subjects were SR/JR/CMO/LMO/Demonstrator (56.1%, 69/123). Nearly one-third of subjects were unmarried (29.3%, 36/123). More than half of doctors were staying alone at current place of stay (54.5%, 67/123) and nearly two-fifth of subjects (36.6%, 45/123) were had children at current place of stay [Table 1].{Table 1}

During the amid of COVID-19 pandemic, the current institution was established as DCH, and lack postgraduate students and interns made all medical doctors from each department to be involved in the duty roster for COVID-19 ICU/wards, so about four fifths of subjects (83.7%, 103/123) were confident in self-protection from COVID-19. Nearly two-fifths of doctors (17.1%, 21/123) were wearing the PPE kit for 5 or more hours per day during duty hours and 13.0% (16/123) of subjects reported absenteeism from duty hours due to PPE-induced skin injuries [Figure 1].{Figure 1}

More than four fifth of subjects (76.4%, 94/123) reported that they have suffered from skin injury after PPE usage during duty hours [Figure 2]. Skin injuries among subjects were mainly due to use of mask and google/face shields (72.4%, 89/123) followed by the use of latex gloves (61.0%, 75/123) and protective clothing (30.1%, 37/123). Commonly reported symptom/sign of skin injuries were indentation and pain on back of ears (61.0%, 75/123); skin itching or rash (35.0%, 43/123); skin soaking in sweat (33.3%, 41/123); and facial itching or rashes (32.5%, 40/123).{Figure 2}

When subjects were asked whether they opted for any preventive measures to avoid skin injury due to PPE kit, nearly two-thirds of subjects (63.4%, 78/123) denied for such preventive measures being used. Subjects those who suffered from the skin injury (n = 94) only two-fifths of them (42.6%, 40/94) sought treatment for the same [Figure 3].{Figure 3}

To find the association of reported skin injuries with the subject's various characteristics, the Chi-square analysis was applied [Table 2] and it was observed that skin injury was more frequent among subjects being subjects falling in the age group <35 years (82.4%, 61/74), males (79.5%, 66/83), senior residents/demonstrator (81.8%, 36/44), married (81.6%, 71/87); having 2 or more members at current place of stay (82.1%, 46/56); wearing PPE kits for 5 or more days in a week during duty hours (84.8%, 56/66); and wearing PPE kits for 3 or more hours while on duty at DCH (82.5%, 66/80), but skin injuries were statistically significant associated with PPE kit wearing days/week; duration of PPE wearing/day; and marital status of subjects (P < 0.05).{Table 2}

 Discussion



The present study made an attempt to find the skin injuries occurred after PPE kit usage among doctors and it was found that 76.4% of subjects have suffered from skin injury after PPE usage during duty hours. In a study by Lan et al., a similar prevalence of skin injury (97.0%) caused by infection-prevention measures among subjects were observed, whereas the study by Navarro-Triviño and Ruiz-Villaverde showed a lower prevalence of skin injury (12.7%) among subjects.[13],[14]

While analyzing more specifically about the which content of PPE kit caused frequent skin injuries among doctors, it was revealed that mask and goggles/face shields caused skin injuries among 72.4% of nurses followed by latex gloves and preventive clothing which caused skin injuries among 61.0% and 30.1% of doctors, respectively. In a study by Singh et al., goggles were the most common culprit agent among all PPE causing any one of the dermatoses (51.92%), followed by N95 masks (30.77%) and face shields (17.31%).[15]

The commonly expressed symptoms/signs for the skin injury occurred was indentation and pain on back of ears (61.0%) and facial itching or rashes (32.5%) caused due to mask or goggles; followed by skin itching or rash (35.0%) and skin soaking in sweat (33.3%) caused due to latex gloves whether powdered or nonpowdered and it was in coherence with findings from Agarwal et al. and Soraganvi et al. studies.[10],[11] Similarly, a study by Hu et al. showed that the most common adverse skin reactions among health-care workers wearing N95 masks were nasal bridge scarring (68.9%) and facial itching (27.9%).[16]

During the amid of COVID-19 pandemic, the current institution was established as DCH, and lack postgraduate students and interns made all medical doctors from each department to be involved in the duty roster for COVID-19 ICU/wards, so only 83.7% of subjects were confident in self-protection from COVID-19. Due to overburdened state, 17.1% of doctors were wearing the PPE kit for 5 or more hours per day during duty hours, which was in coherence with the study by Agarwal et al., where 25% of doctors were wearing PPE for 6 or more hours whereas study by Jiang et al. showed that 85.7% of subject were wearing PPE for more than 4 h.[9],[10] Due to continuous wearing hours of PPE kit, it caused skin injuries among 76.4% of doctors which made 13.0% of subjects absent from duty hours and a review by Cook also approves the present study relevation.[17] Study by Gheisari et al. has shown that skin irritations caused by PPE may cause discouragement of health workers from using it.[8] Similarly, Vidua et al. expressed the concern of increasing numbers of health-care workers having discomfort while using PPE.[18]

The Chi-square analysis showed that daily duty hours were significantly associated with PPE kit wearing days/week; duration of PPE wearing/day; and marital status of subjects (P < 0.05). Similarly, the odds of skin injury were significantly associated with the daily wearing time of PPE kits in the Jiang et al. (95% confidence interval [CI] for odds ratio [OR]: 1.61–3.21) and Lan et al. (95% CI for OR: 1.35–3.01) studies.[9],[13]

The mean age of doctors was 32.8 + 6.2 years, which reflects a quite young working health force in present evolving institution, so the skin injury was more frequent among subjects falling in the age group <35 years (82.4%). Although the association was not found significant on Chi-square analysis, it was observed that skin injuries were quite frequent among subjects males (79.5%) and were not staying alone (82.1%), which shows that males and not staying alone doctors were more cautious to use PPE kit to prevent spreading COVID-19 to others. Study by Kumar et al. showed that 94.2% of subjects working in COVID-19 hospitals were concerned of infecting family members and study by Alnazly et al. showed that fear to infect family members was significantly higher among married subjects.[19],[20]

According to studies by Bishopp et al., Yin, and Darlenski and Tsankov, prophylactic measures such as hydrocolloidal dressings and benzalkonium chloride patch could be considered to alleviate the PPE-induced skin injuries, but in the present study, a hesitancy was observed among subjects when it came to application of preventive measures to avoid skin injury due to PPE kit, as 63.4% of subjects admitted that none of such preventive measures were considered by them.[7],[21],[22] Even among those who had skin injury, 57.4% of them lagged to sought treatment which was a very similar pattern observed in study by Jiang et al., where 82.7% and 55.0% of subjects did not took any preventive measures and treatment for skin injury, respectively.[9]

Limitations

Although the minimal desired sample size was calculated in the present study, during Chi-square analysis, it was found that there were a few of cells where the value was <5 but the association was significant for the variables, so author suggests to take a larger sample for such studies or to do multicentric study instead of single centric study as the present one, to avoid such issues. Apart from limitations, the major strength of the study is that it revealed the skin injuries and its types among doctors in a tribal district of India. Along with that, subjects with skin injuries were treated by dermatologist during and after study period. Apart from this investigator of the present study has planned for a prospective study where subjective examination will be conducted within 24 h of skin injury occurrence.

 Conclusion



Hence, in this study, we explored the characteristics of the skin damage caused due to the PPE and corresponding care and preventive measures required among the doctors caring for COVID-19 patients. The skin adverse effects of PPE among the doctors may result in reduced morale for overloaded work and made them anxious. Hence, an appropriate monitoring of these adverse effects should be done and effective preventive measures should be adopted.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1World Health Organization. Novel Coronavirus (COVID-19) Situation. Available from: https://experience.arcgis.com/experience/685d0ace521648f8a5beeeee1b9125cd. Last accessed on 25 July 2021.
2Fehr AR, Perlman S. Coronaviruses: An overview of their replication and pathogenesis. Methods Mol Biol 2015;1282:1-23.
3Chen Q, Liang M, Li Y, Guo J, Fei D, Wang L, et al. Mental health care for medical staff in China during the COVID-19 outbreak. Lancet Psychiatry 2020;7:e15-6.
4Goulia P, Mantas C, Dimitroula D, Mantis D, Hyphantis T. General hospital staff worries, perceived sufficiency of information and associated psychological distress during the A/H1N1 influenza pandemic. BMC Infect Dis 2010;10:322.
5Shereen MA, Khan S, Kazmi A, Bashir N, Siddique R. COVID-19 infection: Origin, transmission, and characteristics of human coronaviruses. J Adv Res 2020;24:91-8.
6Mahmood SU, Crimbly F, Khan S, Choudry E, Mehwish S. Strategies for Rational Use of Personal Protective Equipment (PPE) among healthcare providers during the COVID-19 Crisis. Cureus 2020;12:e8248.
7Darlenski R, Tsankov N. COVID-19 pandemic and the skin: What should dermatologists know? Clin Dermatol 2020;38:785-7.
8Gheisari M, Araghi F, Moravvej H, Tabary M, Dadkhahfar S. Skin reactions to non-glove personal protective equipment: An emerging issue in the COVID-19 pandemic. J Eur Acad Dermatol Venereol 2020;34:e297-8.
9Jiang Q, Song S, Zhou J, Liu Y, Chen A, Bai Y, et al. The prevalence, characteristics, and prevention status of skin injury caused by personal protective equipment among medical staff in fighting COVID-19: A multicenter, cross-sectional study. Adv Wound Care (New Rochelle) 2020;9:357-64.
10Agarwal A, Agarwal S, Motiani P. Difficulties encountered while using PPE kits and how to overcome them: An Indian perspective. Cureus 2020;12:e11652.
11Soraganvi SM, Hiremath RS, Hiremath PS, Marad MD, Jadhav EP, Hadimani GA. Adverse skin reactions of personal protective equipment on health care workers against COVID -19. South East Asia J Med Sci 2020;4:16-9.
12Available from: https://docs.google.com/forms/d/e/1FAIpQLSdP-c38wNrYzZEAyaNqr1fPiXI6RrdklAtMQXI6KeubjJ1yOQ/viewform?usp=sf_link. Last accessed on 25 July 2021.
13Lan J, Song Z, Miao X, Li H, Li Y, Dong L, et al. Skin damage among health care workers managing coronavirus disease-2019. J Am Acad Dermatol 2020;82:1215-6.
14Navarro-Triviño FJ, Ruiz-Villaverde R. Therapeutic approach to skin reactions caused by Personal Protective Equipment (PPE) during COVID-19 pandemic: An experience from a tertiary hospital in Granada, Spain. Dermatol Ther 2020;33:e13838.
15Singh M, Pawar M, Bothra A, Maheshwari A, Dubey V, Tiwari A, et al. Personal protective equipment induced facial dermatoses in healthcare workers managing Coronavirus disease 2019. J Eur Acad Dermatol Venereol 2020;34:e378-80.
16Hu K, Fan J, Li X, Gou X, Li X, Zhou X. The adverse skin reactions of health care workers using personal protective equipment for COVID-19. Medicine (Baltimore) 2020;99:e20603.
17Cook TM. Personal protective equipment during the coronavirus disease (COVID) 2019 pandemic – A narrative review. Anaesthesia 2020;75:920-7.
18Vidua RK, Chouksey VK, Bhargava DC, Kumar J. Problems arising from PPE when worn for long periods. Med Leg J 2020;88:47-9.
19Kumar J, Katto MS, Siddiqui AA, Sahito B, Ahmed B, Jamil M, et al. Predictive factors associated with fear faced by healthcare workers during COVID-19 pandemic: A questionnaire-based study. Cureus 2020;12:e9741.
20Alnazly E, Khraisat OM, Al-Bashaireh AM, Bryant CL. Anxiety, depression, stress, fear and social support during COVID-19 pandemic among Jordanian healthcare workers. PLoS One 2021;16:e0247679.
21Bishopp A, Oakes A, Antoine-Pitterson P, Chakraborty B, Comer D, Mukherjee R. The Preventative effect of hydrocolloid dressings on nasal bridge pressure ulceration in acute non-invasive ventilation. Ulster Med J 2019;88:17-20.
22Yin ZQ. Covid-19: Countermeasure for N95 mask-induced pressure sore. J Eur Acad Dermatol Venereol 2020;34:e294-5.