Covid-19 has highlighted concerns around shortages of personal protective equipment, but a simple fact remains largely ignored; in our healthcare system, where 77% of staff are women, PPE does not protect female staff as well as their males colleagues.
PPE isn’t a good fit for females
Female healthcare workers (HCWs) report that goggles slip, gowns are too long, face shields push against breasts, and respirators don’t fit their faces. Those that fail fit tests may be forced to choose between wearing shared powered respirators (often in short supply and inadequately cleaned), or wearing ill-fitting items through an obligation to put the needs of patients’ above their own right to safe PPE. Many female HCWs accept this as the norm, unaware that they fail fit tests because PPE is designed primarily for Caucasian men. Shape and size determine whether a person fits PPE, and therefore PPE may be less likely to fit HCWs of some ethnicities.
Women have reported problems with PPE in many industries including science, manufacturing, policing, and the military. Women are not small men. One-size-fits-all equipment designed on male body templates ignores the impact of biological features such as facial geometry and breasts. The media has presented anecdotal evidence regarding the inadequacy of PPE for females HCWs, supporting previously expressed views of trade unions that, surprisingly, have remained quiet on this problem although it impacts the UK’s biggest employer on a national scale.
Disaggregated data is crucial
Data analysis at our own institution has provided empirical evidence that, although males HCWs also fail fit tests, female staff fail respirator fit tests significantly more often. Analysis was not easy as gender or sex weren’t recorded. Nationally, disaggregated data is not collected during fit testing.
Disaggregated data on covid mortality shows that men, and people from ethnic minority backgrounds, are at higher risk, but data is emerging to suggest that younger female UK HCWs are more likely to die from covid-19 versus age-matched non-HCW contemporaries in the general public. Female staff that intubate the tracheas of patients may also be more likely to contract covid-19 than males that intubate. At the same time, there is increasing evidence supporting the spread of SARS-CoV-2 by aerosols generated by speaking and coughing.
An issue ignored
Although Public Health England acknowledges the role of fit testing in its national guidance, it seems to be unaware of the impact of sex on PPE. Guidance from advisory bodies such as the Royal College of Physicians, the Intensive Care Society, and Faculty of Intensive Care Medicine don’t mention the impact of sex, and also fail to include the essential role of fit testing respirator masks to ensure staff safety. We encourage medical institutions to urgently acknowledge these issues, thereby fulfilling their duty of care to protect both staff and patients.
Change is needed
Internationally, the type of respirators available for supply are designed and manufactured as a single, mainly “male” sized mask. Manufacturers acknowledge that a range of different models of respirators should be available whilst fit-testing staff to match different face shapes and sizes, increasing the chance of a safe fit. Nevertheless, disposable respirators remain single size.
In the UK, hospitals do not have the ability to procure respirators and PPE for themselves, and have to work with what they are sent. Most institutions tend to have one or two models of respirator and are sent new models every few months as stock levels change. Cross border shortages of PPE remain, and supply lines are fragile. It is likely that the UK’s exit from the European Union will have a negative impact.
Solutions
Action is urgently required to address this sex discrimination. Change is possible if it is committed to. Transport for London identified that ill-fitting PPE risked the safety of female employees, and amended ordering patterns to source equipment specially designed to fit females that fulfilled their safety specifications.
Acknowledgement from government bodies and regulators will influence manufacturers. Covid-19 has driven innovation at a speed we never thought was possible. Traditional industrial processes have been bypassed to design bespoke respirators and PPE through adaptive engineering. Innovative 3D printed personalised respirators from facial scans are already in development, driven by the need for safe respirators for female staff. This approach will cost, but the government has already demonstrated willingness to pay large sums of money for inadequate PPE at the taxpayers’ expense.
Let’s get our priorities right
The health and wellbeing of healthcare workers must be our priority. As a society, industry, and profession, we need to decide what is acceptable. Are we happy to ignore a major health and safety issue that discriminates against female colleagues, putting 77% of the workforce at risk?
Abhijoy Chakladar is a consultant anaesthetist at Brighton & Sussex University Hospitals NHS Trust. @Chakladar_A
Anna Ascott is an internal medicine trainee at Brighton & Sussex University Hospitals NHS Trust. @Anna_Ascott_
Competing interests: None declared