LTCcovid Country Profiles

Responses to 3.09. Access to Personal Protection Equipment (PPE) in the Long-Term Care sector

Australia

The Australian government worked with state and territory governments since the beginning of the pandemic to provide aged care facilities with PPE. As of October 2, 2020, 17 million masks, 4 million gowns, 11 million gloves and 4 million goggles and face shields had been provided to aged care facilities. But, even with this support, unions consistently reported PPE shortages within the facilities (Charlesworth and Low, 2020).

References:

Charlesworth, S & Low, L-F (2020) The Long-Term Care COVID-19 situation in Australia. Report in LTCcovid.org, International Long-Term Care Policy Network, CPEC-LSE, 12 October 2020.

Last updated: December 22nd, 2021

British Columbia (Canada)

Health authority owned and operated facilities were supported in procuring PPE, managing staffing availability, and IPC education and training, whereas private and affiliate sites felt that they were left to manage independently unless an outbreak occurred. For example, one Health Authority provided PPE to private providers with 3 days notice, where others only provided supplies to health authority owned and operated facilities. Private LTC providers were left to source PPE through local community initiatives or unauthorized distributors, which often did not meet proper IPC requirements. Two policies were introduced regarding PPE: Emergency Prioritization in a Pandemic Equipment (PPE) Allocation Framework March 25, 2020 and Personal Protective Equipment (PPE) Supply, Assessment, Testing and Distribution Protocol May 1, 2020 (https://news.gov.bc.ca/files/1.25.2021_LTC_COVID-19_Response_Review.pdf).

Last updated: November 9th, 2021

Denmark

The shortage of PPE (and a decision to prioritize PPE for the hospitals) has influenced the recommendations for how to handle the disease in the nursing homes. Initially, physical distance was considered sufficient but later (when the supply of PPE seemed sufficient), wearing PPE was considered essential and regardless of whether there were symptoms of the disease. The reason for the shortage of PPE in the municipalities was that early in the outbreak (March 10th, 2020), the Danish Medicines Agency approached the providers of PPE and asked them to prioritize delivery to the regions and therefore for hospitals. The municipalities therefore needed to find other providers and this led to a shortage of PPE in the municipalities (https://ltccovid.org/2020/05/28/new-country-report-the-covid-19-long-term-care-situation-in-denmark/).

Last updated: May 25th, 2023

Finland

Access to PPE was an issue for Finland early on. In late March, the Ministry of Social Affairs and Health (MSAH) requested that the National Emergency Supply Agency release and distribute its stockpile to university hospital districts and municipalities. After expressed concern over lack of PPE in social care services/spaces, MSAH conducted a survey of municipalities that revealed 67% of respondents felt it impossible to follow the pandemic regulations, mainly because of a lack of protective equipment. For that reason, on May 13th the ministry mandated that the use of protective equipment was obligatory.

Source:

https://drive.google.com/file/d/19z_e5j7bcPxUYh2qLBa6VwrVDVnWilv7/view, page 27.

Last updated: November 23rd, 2021

France

Access to PPE was delayed across the social care sector and is considered by the Senate as the key explanation behind the high level of Covid-19 infection in care homes (http://www.senat.fr/rap/r20-199-1/r20-199-11.pdf). Critics have commented on the over-focalisation in providing PPE to the hospital sector and the insufficient attention given to the care sector by local authorities and health actors (source). Care homes were only included into the PPE provision circuit from 22nd march, despite blue plans being activated on 6th march. Access to tests was heavily restricted (source). 

Until the end of April 2020 there were large insufficiencies in the provision of PPE despite a communication on 13th March stating care homes would have access where need was identified, and central/local conflicts, for example with the state requisitioning regional circuits to social care settings. Domiciliary care settings were hardest hit by PPE crisis, for example with guidance to local pharmacies holding masks to limit use to domiciliary care workers. Some domiciliary care agencies estimate the PPE received covered only 40% of their needs. Even where masks were allocated additional PPE including glasses and FFP2 masks and gowns were not accessible (https://www2.assemblee-nationale.fr/static/15/pdf/rapport/i3633.pdf). One inspection authority followed employment regulation and condemned a domiciliary care agency for not having provided adequate PPE to employees (http://www.senat.fr/rap/r20-199-1/r20-199-11.pdf). 

The care sector has expressed a feeling of ‘abandonment’ as a result of the struggles to access PPE, especially in comparison to the health sector which benefitted from a coordinated and rapid response. However, qualitative studies have highlighted the level of community initiatives upon which care providers depended as a result, to help provide home-made PPE etc. 

Last updated: October 23rd, 2024

Germany

Across Germany people need to wear surgical or FFP2-masks in public transports and shops since 19 January 2021.

Occupational Health and Safety Regulations stipulate that staff in care homes (https://www.bgw-online.de/SharedDocs/Downloads/DE/Corona/SARS-CoV-2-Arbeitsschutzstandard-Pflege-stationaer_Download.pdf?__blob=publicationFile) and in home care (https://www.bgw-online.de/SharedDocs/Downloads/DE/Corona/SARS-CoV-2-Arbeitsschutzstandard-Pflege-ambulant_Download.pdf?__blob=publicationFile) have to wear FFP-2 masks. In addition, full PPE has to be worn in high risk situations.

At risk groups (people aged 60 and older), people with specific medical risks and people with limited means (recipients of benefits) in Germany receive FFP2 masks for free (https://www.bundesgesundheitsministerium.de/service/gesetze-und-verordnungen/guv-19-lp/schutzmv.html?fbclid=IwAR1ZsHTuu5cNRkbvqnAlRul821iBgJfopUoqu00ygGcODkuAG3ZalNltbXk).

The Federal Government has increased its stock of PPE and increased distribution as infection rates were rising in Winter 2020. The Federal Ministry of Health has also purchased rapid tests to facilitate opening up social life again (https://www.covid19healthsystem.org/countries/germany/livinghit.aspx?Section=2.1%20Physical%20infrastructure&Type=Section). However, rapid tests promised to the German population free by the Federal Minister of Health of charge from 1 March 2021 have been delayed. According to figures for the ECDC Germany is 22nd out of 27 countries in terms of testing (https://www.zdf.de/nachrichten/politik/corona-spahn-schnelltests-verschoben-100.html).

At the beginning of the pandemic federal states have taken different routes to support care providers with protective equipment. A detailed overview can be found here: Lorenz-Dant, 2020).

A study conducted among LTC workers between April and May 2020 showed that respondents found procurement of PPE was quite laborious. Respondents would have preferred a centralised storage and distribution system. Respondents also requested systematic and regular COVID-19 tests as well as rapid tests and improved communication of test results (https://link.springer.com/article/10.1007/s00391-020-01801-7 ).

Already in February 2020, Germany was involved in plans to procure protective equipment for medical staff through a joint European initiative.  In early March 2020, Germany prohibited the export of protective equipment to other countries and the Federal Ministry of Health took responsibility to procure protective equipment for doctors’ surgeries, hospitals and federal authorities (https://www.bundesgesundheitsministerium.de/coronavirus/chronik-coronavirus.html).

References

Lorenz-Dant, K. (2020) Germany and the COVID-19 long-term care situation. LTCcovid, International Long Term Care Policy Network, CPEC-LSE, 26 May 2020. Available at: https://ltccovid.org/wp-content/uploads/2020/05/Germany_LTC_COVID-19-26-May-2020.pdf (Accessed 3 February 2022)

Last updated: February 12th, 2022   Contributors: Klara Lorenz-Dant  |  

Hong Kong (China)

Following a survey by the Hong Kong Social Workers and Welfare Employee Union in February 2020 that showed more than one quarter of respondents did not receive adequate PPE from their organisations, the Social Welfare Department gave 3 rounds of special allowances to procure PPE and sanitising items (total costs HK$34 million) to residential care homes for older people, community care providers and others. In additional, all residential care units were informed that they would receive 1 million face masks (https://ltccovid.org/wp-content/uploads/2020/07/Hong-Kong-COVID-19-Long-term-Care-situation_updates-on-8-July-1.pdf).

Last updated: November 9th, 2021

Israel

Israel faced limited PPE alongside most of the globe during its first lockdown in March/April. Equipment was scarce, especially in hospitals and other health providers treating patients. In April 2020, the LTCF Association submitted an ‘urgent petition’ to the Israeli Supreme Court, which included an emergency budget for protective gear. The petition was rejected but became one of the main objectives of the national task force that organized central purchase of PPE for all LTC institutions and also surpervised the management of the PPE stock in all LTC facilities. (Tsadok-Rosenbluth et al, 2021). Little has been reported on the matter since, except for some coverage in September that indicated a shortage of gloves and robes/protective suits headed into the second wave (source: Times of Israel).

Last updated: December 5th, 2021

Italy

Another relevant issue in Italy was the lack of Personal Protective Equipment (PPE) for Long Term Care services, including care home workers. Italy faced an enormous shortage of masks, tests, gowns, which deeply affected the social care and healthcare personnel. New PPE supplies were primarily directed to hospitals and nursing homes were left struggling to find the adequate equipment to protect their workers and residents. In the Lombardy Region, the first supply of masks for nursing homes arrived on the 12th of March 2020 but proved to be insufficient to cover their actual needs. In the national ISS survey, respondents stated that some of the major problems encountered during the crisis were related to the weak guidelines given to limit the spread of the disease, the lack of medical supplies, the absence of care workers, and the difficulty to promptly transfer positive patients into hospitals. All of these factors were considered to have allowed the virus to spread in LTC facilities, resulting in an incredibly high number of infected residents and care personnel, together with high mortality.

In 2021 PPE shortages are no longer an issue, but acquisition of the materials needed is still the responsibility of care providers.

Last updated: December 4th, 2021   Contributors: Eleonora Perobelli  |  Elisabetta Notarnicola  |  

Japan

There are some reports of shortages of PPE (https://onlinelibrary.wiley.com/doi/full/10.1002/jgf2.366; https://programs.wcfia.harvard.edu/files/us-japan/files/margarita_estevez-abe_covid19_and_japanese_ltcfs.pdf).

Last updated: November 9th, 2021

Republic of Korea

By early March 2020 Korea had a strategic plan to distribute supplies of PPE: the Central Disaster Management Headquarters established a working group and IT system to distribute 5.46 million masks to long-term care providers.

Last updated: November 25th, 2021   Contributors: Elisa Aguzzoli  |  

Netherlands

PPE was scarce in the early months of the pandemic and hospitals were given priority in government efforts to alleviate the problem. This was reinforced by regional networks of emergency care (ROAZ) being given responsibly for distributing PPE, which disadvantaged LTC. During the first wave, 90% of masks went to hospitals and only 10% to nursing homes. Care homes were asked to make their equipment available to hospitals (https://drive.google.com/file/d/1Ji-iDCjC-8EbBpV0dW_xlz780uvU7F–/view).

During the first wave it was reported that the use of PPE was strictly regulated due to shortage, could only be used under specific circumstances. Only those LTC personnel that were at risk received PPE. The Dutch Health and Youth Inspectorate inquired whether the LTC providers have sufficient PPE (24th April 2020) (https://ltccovid.org/wp-content/uploads/2020/05/International-measures-to-prevent-and-manage-COVID19-infections-in-care-homes-11-May-2.pdf).

A study analysing the minutes and other meeting documents of Outbreak Teams operating in care homes (including residential and nursing care homes) during weeks 16 to 23 of 2020 (covering the first two waves of COVID infections in the Netherlands) shows that there were still PPE shortages at that stage and costs were high. This resulted in Outbreak Teams considering the sterilisation and reuse of PPE (van Tol et al, 2021).

References:

van Tol LS, Smaling HJA, Groothuijse JM, et al COVID-19 management in nursing homes by outbreak teams (MINUTES) — study description and data characteristics: a qualitative study BMJ Open 2021;11:e053235. doi: 10.1136/bmjopen-2021-053235

Last updated: January 6th, 2022

Pakistan

Speaking to authors of a recent report in May 2020, the owner of an old age home indicated that the government had not issued any particular Standard Operating Procedures for old age homes. They also had not yet been contacted for masks or safety kits – it was therefore left to the old age home to purchase overpriced masks to keep residents and staff safe. The owner of the home added that a health advisory was issued by the government to some shelter homes, even though the residents of such homes are more capable of looking after themselves than those in old age homes, where risks are doubled due to a reliance on receiving care (The Global Platform Reader).

Last updated: January 27th, 2022   Contributors: Daisy Pharoah  |  

Poland

Lack of PPE in care homes has been a challenge, partly addressed by donations from private companies, NGOs and individuals donors. Lack of procedures for coordinated/joint purchases of PPE equipment for several care homes made it harder for individual care home facilities to get adequate PPE supplies (sources: Domy-pomocy-spolecznej-w-dobie-pandemii-19-11.pdf;  Long-term care report – Publications Office of the EU).

Last updated: November 24th, 2021   Contributors: Joanna Marczak  |  Agnieszka Sowa-Kofta  |  

Singapore

Already in 2018, Singapore introduced National Infection Prevention and Control Guidelines for Long Term Care Facilities. In addition, the Agency for Integrated Care provided webinars to review practices outlined with care providers and to provide up-to-date guidelines. In addition, the Ministry of Health issues current advisories.

The Agency for Integrated Care also drew on the national stockpile to ensure that all nursing homes, irrespective of provider, had sufficient levels of PPE. The supply of PPE was provided based on ‘the facilities’ staff size and level of precaution required of specific care services’.

Source:

https://ltccovid.org/wp-content/uploads/2020/08/The-COVID-19-Long-Term-Care-situation-in-Singapore-27July-2020.pdf.

Last updated: November 23rd, 2021

Spain

The “Report of the Covid 19 and residences working group ” highlighted the difficulties care homes encountered sourcing effective PPE for their staff during the first wave of the Covid-19 pandemic; especially between March and mid-April 2020. During the first wave, care homes that did not purchase PPE in January or early February at the latest, were unable to obtain PPE afterwards. At the time, there were reports of plastic bags being used instead and of the sharing of masks between staff (Del Pino et al., 2020). The lack of supply from abroad was due to the global lack of resources.

However, there are examples of hospitals providing some of their own PPE to local care homes in the early part of the pandemic (Saez-Lopez, 2021).

While massive global demand for PPE is difficult to manage, especially if sufficient stock has not already been procured, the report recommends that an essential part of contingency planning is to ensure a sufficient stock of PPE that should last at least one month. This includes PPE for residents, care home staff and family members in the event of an outbreak that affects large numbers of residents.

The report also recommends offering training about COVID-19 and its transmission to all care home care home staff, as well as training in the use of PPE. The report also states that it is especially important for care home staff to be provided with PPE when treating infected residents

References:

Del Pino E., Moreno-Fuentes F.J., et al. (2020) Informe Gestion Institucional y Organizativa de las Residencias de Personas Mayores y COVID-19: dificultades y aprendizajes. Instituto de Politicas y Bienes Publicos (IPP-CSIC) Madrid.

Sáez-López P, Arredondo-Provecho AB. (2021) Experiencia de colaboración entre hospital y centros sociosanitarios para la atención de pacientes con COVID-19. Rev Esp Salud Pública. 95: 14 de abril e202104053.

Last updated: June 29th, 2022   Contributors: Sara Ulla Díez  |  

Sweden

There was national scarcity of Personal Protection Equipment (PPE), which affected the LTC sector in particular. The Corona Commission‘s report in December 2020 highlighted that the lack of PPE in LTC settings contributed to the spread of the virus. It took unreasonably long to clarify and define the need for PPE in LTC. The Public Health Authority mentioned the use of masks and shields in LTC for the first time on the 7th May, however a proper recommendation to use shields and masks in personal care of people with confirmed or suspected COVID was not made until the 25th of June 2020 (Szebehely, 2020).

On February 2020, Sweden signed an agreement to enable joint EU-wide procurement of medical counter-measures, including PPE. Companies that produce PPE and medical devices expanded their production where possible. There was no national mechanism to assess the stocks of PPE, as the regions and municipalities were responsible for managing their own medical stocks including PPE. Many municipalities did not have sufficient stocks of PPE and rationed what was available, prioritising hospitals (Johansson and Scho?n, 2020 and Szebehely, 2020).

References:

Last updated: February 13th, 2022

England (UK)

Overview

The government has faced criticism and legal challenges for failures in the availability and distribution of PPE, particularly in the early phase of the pandemic. There was a significant shortage of PPE (face masks, aprons, gloves and visors). Furthermore, the central stockpile was designed for a flu pandemic. According to editorial published in British Medical Journal (Scally et al. 2020) , the government “failed to protect staff in the NHS and social care by not delivering sufficient amounts of personal protective equipment (PPE) of the right specification, again deviating from WHO advice”. Directors in the social care sector specifically claimed that “a critical lack of PPE and testing of social care staff and service users is putting them at unnecessary risk of exposure”. Resentment about prioritisation of the NHS for distribution of PPE has been expressed.

Policy Measures

Initial steps announced on March 18, 2020, included the distribution of PPE to every care home and care home provider to ensure that they had at least 300 fluid repellent face masks for immediate needs, followed by a further tranche of items of PPE in early April. However, the government did acknowledge PPE supply shortages and published a PPE plan on April 15 with the goal that “everyone should get the personal protective equipment (PPE) they need”.

In the social care sector, providers have traditionally organised the PPE they required through the market. The adult social care action plan announced that the government was now stepping in with arrangements to support the supply and distribution of PPE. A parallel supply chain has been established for emergency PPE provision, involving new logistics networks and support from the army and including a national supply disruption response (NSDR) system to respond to emergency PPE requests, and a 24/7 helpline for providers who have an urgent requirement.

On September 30, the government announced that they were extending existing infection control funding with an additional £388.3 million. The funding is intended to help providers with PPE costs, amongst other needs.

Published on November 3, 2021, the Adult social care: COVID-19 winter plan 2021 to 2022 sets out the key elements of national support available for the social care sector for winter 2021 to 2022. This set out that free PPE for COVID-19 needed to the adult social care sector would continue to be provided until the end of March 2022, with sufficient stock to cope throughout winter. Following a consultation on extending free PPE to the health and care sector after the current end date of 31 March 2022, on 13th January 2022 the government announced that free PPE will continue to be provided to health and care providers until 31st March 2023 or until infection control measures are withdrawn.

Issues with PPE

The need for appropriate PPE in care homes is of critical importance for the safety of residents and staff, particularly in light of the fact that care homes were accepting hospital discharges who were positive for COVID-19.  A survey launched by The Queen’s Nursing Institute (2020) in the early weeks to the pandemic found that 21% of respondents (from across the UK) had accepted COVID-19 positive patients into their facilities. 43% reported accepting people whose COVID-19 status was unknown. Although most respondents (74%) reported that PPE was made available by their employers, some were not provided with PPE and had to improvise by obtaining it themselves or making it. Furthermore, even for those who were provided with PPE, there was fear and anxiety around whether it was adequate to mitigate the spread of COVID-19 and keep them and their residents safe.

Announcements by the government about the number of items of PPE being delivered have been questioned. According to the BBC, over half of the 1.2 billion items of PPE the Department of Health announced on May 10 for health and social care providers in England were surgical gloves, with gloves individually counted rather than in pairs and faulty equipment subsequently being recalled. It is not clear how the protective equipment delivered was divided between health and social care and there have been suggestions that delivery systems have been failing to provide to care homes, requiring them to secure their own supplies individually. One example reported was that of a care provider who was provided with 400 face masks while requiring over 35,000 masks a week. In a survey of English care homes at the end of May and early June, 70% of care home managers reported insufficient PPE supplies, with 34% of providers purchasing supplies directly from abroad.

In addition to being captured in the media, dissatisfaction with PPE provision and policy has come through in some academic literature. A qualitative study published in February 2021 obtained results through interviews with ten care home managers in the East Midlands of England. Participants felt that control over pandemic response was taken away from care home managers – who were normally quite competent at managing the supply chain – when PPE supplies were centralised. This occurred in spite of the fact that they were responsible for making high stake decisions in circumstances defined by multiple and sometimes conflicting sources of information (Marshall et al., 2021).

References:

Scally, G. et al. (2020). The UK’s public health response to covid-19. BMJ 2020; 369 doi: https://doi.org/10.1136/bmj.m1932

Marshall, F., Gordon, A., Gladman, J. R. F., & Bishop, S. (2021). Care homes, their communities, and resilience in the face of the COVID-19 pandemic: interim findings from a qualitative study. BMC Geriatrics, 21(1). https://doi.org/10.1186/S12877-021-02053-9

Queen’s Nursing Institute. (2020). The Experience of Care Home Staff During Covid-19. A Survey Report by The QNI International Community Nursing Observatory. July. https://www.qni.org.uk/wp-content/uploads/2020/08/The-Experience-of-Care-Home-Staff-During-Covid-19-2.pdf [accessed 11/10/2020]

Last updated: March 24th, 2022   Contributors: William Byrd  |  Nina Hemmings  |  Adelina Comas-Herrera  |  Daisy Pharoah  |  

Northern Ireland (UK)

Issues with PPE provision has come through in some recent academic literature. For example, a study by Greene et al. (2020), which found that lack of reliable access to PPE in the first phase of the pandemic (before July 2020) was a robust predictor of clinically significant mental distress in health and care workers across the UK. This highlights that the impacts of unreliable access to PPE go beyond compromising physical health of this workforce.

References:

Greene, T., Harju-Seppänen, J., Adeniji, M., Steel, C., Grey, N., Brewin, C. R., Bloomfield, M. A., & Billings, J. (2020). Predictors and rates of PTSD, depression and anxiety in UK frontline health and social care workers during COVID-19. MedRxiv, https://pubmed.ncbi.nlm.nih.gov/33968317/

Last updated: March 24th, 2022   Contributors: Daisy Pharoah  |  

Scotland (UK)

The Adult Social Care – Winter Preparedness Plan: 2021-22 set out the measures that will be applied across the adult social care sector to meet the challenges over the winter 2021 – 2022. Following a review of the existing PPE support arrangements, it has been confirmed that the PPE Hubs and PPE Support Centre, which provide free PPE to providers across the sector where supply routes fail, and to unpaid carers who are unable to access PPE through their normal routes, will continue to operate until end March 2022. For care providers, payments for PPE over and above usual amounts as a result of the pandemic have also been extended to end March 2022 as part of the Financial Support for Adult Social Care Providers (see also Extending PPE access to all social care providers).

Last updated: March 29th, 2022   Contributors: Jenni Burton  |  David Henderson  |  David Bell  |  Elizabeth Lemmon  |  

United Kingdom

Availability of PPE: impact on mental health

The need for appropriate PPE in care homes is of critical importance for the safety of residents and staff, particularly in light of the fact that care homes were accepting hospital discharges who were positive for COVID-19. However, issues with PPE provision has also come through in some recent literature. A survey launched by The Queen’s Nursing Institute (2020) in the early weeks to the pandemic found that 21% of respondents from across the UK had accepted COVID-19 positive patients into their facilities. 43% reported accepting people whose COVID-19 status was unknown. Although most respondents (74%) reported that PPE was made available by their employers, some were not provided with PPE and had to improvise by obtaining it themselves or making it. Furthermore, even for those who were provided with PPE, there was fear and anxiety around whether it was adequate to mitigate the spread of COVID-19 and keep them and their residents safe. Results from this survey were collected in early 2020 from 163 care staff across the UK.

A study by Greene et al (2020) found that lack of reliable access to PPE in the first phase of the pandemic (before July 2020) was a robust predictor of clinically significant mental distress in health and care workers across the UK. This highlights that the impacts of unreliable access to PPE go beyond compromising physical health of this workforce.

References:

Greene, T., Harju-Seppänen, J., Adeniji, M., Steel, C., Grey, N., Brewin, C. R., Bloomfield, M. A., & Billings, J. (2020). Predictors and rates of PTSD, depression and anxiety in UK frontline health and social care workers during COVID-19. MedRxiv, 2020.10.21.20216804. https://doi.org/10.1101/2020.10.21.20216804

Queen’s Nursing Institute. (2020). The Experience of Care Home Staff During Covid-19. A Survey Report by The QNI International Community Nursing Observatory. July. https://www.qni.org.uk/wp-content/uploads/2020/08/The-Experience-of-Care-Home-Staff-During-Covid-19-2.pdf [accessed 11/10/2020]

Last updated: March 24th, 2022   Contributors: Daisy Pharoah  |  

United States

An electronic survey of 152 nursing home staff from 32 states, including direct care staff and administrators carried out from the 11th May to the 4th June 2020 showed that by then availability of PPE had improved compared to the earlier part of the pandemic. However, there were still shortages, resulting in extended reuse of PPE and supplementation with homemade PPE.  Staff in management roles spending large amounts of time (and money) to obtain sufficient supplies of PPE, having to rely on unconventional suppliers.

Last updated: January 2nd, 2022