At the beginning of March, Roberto Stella, a GP, from Busto Arsizio near Milan, became the first doctor to die from covid-19 in Italy. Only days earlier he had attended a Regional Health Board meeting where he had warned that the personal protective equipment (PPE) available to GPs was inadequate. He had asked for adequate protection to be provided to all GPs coming into contact with patients, arguing that many people are asymptomatic for 48 hours while shedding the virus so it is impossible to tell whether patients may be covid-19 positive when they present.
His death was quickly followed by those of three other GPs in the hardest hit Lombardy region, and I learned of these deaths in an email from an Italian doctor friend of mine, Giuseppe Rivolta, on 10 March. Rivolta had been at the Regional Health Board meeting with his colleague and friend Roberto Stella. Rivolta pointed out to me in the email that the European Centre for Disease Prevention and Control (ECDC) indicates that FFP2 or higher PPE should be the standard for doctors. However, rather than following the ECDC recommendations the Italian government appears instead to have turned to an older directive issued by the World Health Organization (WHO). This WHO directive was not written with Europe in mind, it was developed to offer a sustainable solution for countries where proposing an expensive FFP2 mask would have been impractical and where a surgical mask was an acceptable alternative.
Italian doctors pointed out that if the government had said that they could not get adequate PPE so healthcare staff would have to make do with what was available, medical staff would have accepted the position and just got on with it. It was the insistence that this was the correct protection that they found particularly upsetting.
In the UK, the BMA has been vocal and persistent about bringing the issue of PPE to the government’s and the media’s notice. The BMJ has launched a campaign for #properPPE.
Despite this, distribution of PPE is still erratic. When I worked in my practice on Good Friday, there were gloves and paper masks, but little else. We have a hot hub where we can send patients we suspect may be covid-19 positive and where they will get observations (blood pressure, temperature and oxygen saturation) but no testing.
It seems that a strategy similar to Italy’s may be developing in the UK. The government appear to be adjusting their recommendations to what PPE is available rather than what PPE is adequate to protect those healthcare staff working with possibly infected patients.
Part of the problem is that every patient may be infected. Rivolta wrote “The experience of these last weeks teaches us that the danger is not with the easily identifiably-ill patient with covid-19 symptoms, but with those patients who are asymptomatic and are not seen as problematic. If GPs want to be operationally safe then the masks they use must be FFP2 standard or above”.
There is a hospital in Naples where no doctor has been infected with covid-19. It is an infectious diseases centre when protection is good and hygiene safety rules are strictly adhered to. PPE here seems to work in the way it should.
Rivolta was tested as a contact of Stella’s. He had no cough, no fever and no shortness of breath. He was found to be covid-19 positive and a CT scan showed moderate interstitial pneumonia. He did not know he was ill. He and his family are now in quarantine.
We have a duty during the coronavirus pandemic to protect the medical and nursing staff at the same time as we care for our patients. In the UK the airline safety procedures are often quoted with regard to the health service. One of these rules is, of course, “Adjust your own oxygen supply before you attend to others.” This applies to health care staff too. If we can’t protect our workers, we can’t protect our patients.
Mary McCarthy is vice president (and BMA representative) of the Union of European General Practitioners (UEMO), and a GP at the Belvidere Medical Practice, Shrewsbury
Giuseppe Rivolta is a member of the Italian delegation of UEMO, Secretary of the National Autonomous Union of Italian Doctors (SNAMI0 in Lombardy, and a GP at “Duturnet” General Medicine Network, Erba (Como) Italy
Competing interests: None declared