INTERNATIONAL REPORTS

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


England (UK)

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 (https://www.nao.org.uk/wp-content/uploads/2020/06/Readying-the-NHS-and-adult-social-care-in-England-for-COVID-19.pdf; https://goodlawproject.org/news/the-ppe-fiasco/). In the view of the British Medical Journal, 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’ (https://www.bmj.com/content/369/bmj.m1932). Directors in the social care sector specifically pointed to ‘a critical lack of PPE and testing of social care staff and service users is putting them at unnecessary risk of exposure’ (https://www.adass.org.uk/statement-by-adass-and-unions-on-ppe-in-the-care-sector). Resentment about prioritisation of the NHS for distribution of PPE has been expressed (https://www.ft.com/content/6afb06d6-abd6-4281-ac16-74f500f096d0).

Initial steps announced on 18 March 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 (https://www.gov.uk/government/publications/coronavirus-covid-19-personal-protective-equipment-ppe-plan/covid-19-personal-protective-equipment-ppe-plan). However, the government did acknowledge PPE supply shortages and published a PPE plan on 15 April with the goal that ‘everyone should get the personal protective equipment (PPE) they need’ (https://www.gov.uk/government/publications/coronavirus-covid-19-personal-protective-equipment-ppe-plan/covid-19-personal-protective-equipment-ppe-plan). Announcements by the government about the number of items of PPE being delivered have been questioned. According to the BBC, over half of the 1.2bn items of PPE the Department of Health’s announced on 10 May for health and social care providers in England were surgical gloves, with gloves individually counted rather than in pairs (https://www.bbc.co.uk/news/health-52254745) and faulty equipment subsequently being recalled (https://www.carehomeprofessional.com/recall-notice-issued-for-faulty-ppe-masks-sent-to-care-homes/). 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 (https://www.theguardian.com/world/2020/may/09/uk-care-homes-scramble-to-buy-their-own-ppe-as-national-deliveries-fail). In the survey of English care homes at the end of May and early June mentioned above, 70% of care home managers reported insufficient PPE supplies, with 34% of providers purchasing supplies directly from abroad.

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 (https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/879639/covid-19-adult-social-care-action-plan.pdf). 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 (https://www.gov.uk/government/publications/coronavirus-covid-19-personal-protective-equipment-ppe-plan/covid-19-personal-protective-equipment-ppe-plan).

Last updated: September 8th, 2021


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

Last updated: September 8th, 2021


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 (https://ltccovid.org/wp-content/uploads/2020/10/Australia-LTC-COVID19-situation-12-October-2020-1-1.pdf).

Last updated: September 8th, 2021


Canada (British Columbia)

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: September 8th, 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), 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: September 8th, 2021


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

 

Last updated: September 8th, 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). 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).

Last updated: September 8th, 2021


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 (https://ltccovid.org/wp-content/uploads/2020/05/Germany_LTC_COVID-19-26-May-2020.pdf).

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).

 

Last updated: September 8th, 2021   Contributors: Klara Lorenz-Dant  |  


Hong Kong

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: September 8th, 2021


Israel

Israel faced a risk of limited PPE alongside most of the globe during its first lockdown in March/April. 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 (https://www.timesofisrael.com/as-infections-stay-high-officials-warn-of-ppe-shortage-in-israel-from-september/). 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 taskforce developed soon afterwards (https://journal.ilpnetwork.org/articles/10.31389/jltc.75/).

Last updated: September 8th, 2021


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: September 8th, 2021


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).

Last updated: September 8th, 2021


Republic of Korea

The Ministry ordered and distributed low-cost masks for care workers. It’s not clear whether providers had sufficient access to PPE, however the government took pains to ensure domestic supply through centralised purchasing and limiting exports.

Last updated: September 8th, 2021


Spain

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, with example of use of plastic bags or sharing of masks between staff (https://digital.csic.es/bitstream/10261/220460/5/Informe_residencias_COVID-19_IPP-CSIC.pdf).

Last updated: September 8th, 2021


Sweden

The Corona Commission 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, there were no channels to report needs or organise delivery. 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 (https://www.government.se/legal-documents/2020/10/dir.-202074/). Shortages of PPE have been identified as contributing to the spread of Covid-19 in care home settings. In the initial months the government recommendation was to follow the legislation on basic hygiene routines. The Public Health Agency mentioned the use of facemasks and shields in eldercare services in May 2020, however it was left to the local care homes or home-care units to decide whether to use masks and/or shields.  Only on June 25, the Public Health Agency recommended the use of shields and facemask in personal care of all care recipients with suspected or confirmed COVID-19.  The regions and municipalities are responsible for managing their own medical stocks including PPE, consequently there was no overall national picture of national situations.  Many municipalities did not have sufficient stocks of PPE (e.g. there was a shortage of alcohol disinfectants, gloves, protective coats, and face masks, while protective visors were usually not available at all) and they began to ration available equipment and prioritize the needs of hospitals. This in turn led to the recommendations when protective equipment was necessary in e.g. care homes being surrounded by strict conditions.

During the first months of the pandemic, the country lacked sufficient organization, logistics for warehousing and distribution while guidelines for the use of PPE in various care situations were also unclear.  It was pointed out that there have previously been shortcomings in basic hygiene routines and that the staff did not have sufficient competence to protect themselves and care users from infection (https://aldrecentrum.se/wp-content/uploads/2021/02/Johansson-L.-Sch%C3%B6n-P.-2021.-Governmental-response-to-the-COVID-19-pandemic-in-Long-Term-Care-residences.pdf; https://ltccovid.org/wp-content/uploads/2020/07/The-COVID-19-Long-Term-Care-situation-in-Sweden-22-July-2020-1.pdf).The National Board for Health and Welfare (NBHW) was further designated to coordinate material supply to the healthcare among the regions, in order to ensure optimal use of the critical supply (https://www.sciencedirect.com/science/article/abs/pii/S2211883720300812).

Last updated: September 8th, 2021