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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 7  |  Issue : 1  |  Page : 134-140

Skin damage due to personal protective equipment among health-care professionals in a dedicated COVID-19 hospital of tribal India


1 Department of Dermatology, Government Medical College, Shahdol, Madhya Pradesh, India
2 Department of Community Medicine, Government Medical College, Shahdol, Government Medical College, Shahdol, Madhya Pradesh, India
3 Department of Community Medicine, SHKM Government Medical College, Nalhar, Haryana, India
4 Department of Community Medicine, Government Medical College and Hospital, Chandigarh, India

Date of Submission22-Nov-2021
Date of Decision16-Jan-2022
Date of Acceptance29-Jan-2022
Date of Web Publication27-Jun-2022

Correspondence Address:
Dr. Vikas Gupta
Department of Community Medicine, Government Medical College, Shahdol, Madhya Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/bjhs.bjhs_123_21

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  Abstract 


BACKGROUND: Health-care professionals (HCPs) are at much greater risk of infection due to the exposure to the highly infectious bodily fluids and droplet nuclei and needed use of personal protective equipment (PPE) to reduce the transmission risk. The present study was conducted with an aim of estimating the prevalence of various types of skin injuries among HCPs due to PPE usage.
MATERIALS AND METHODS: This descriptive cross-sectional study was conducted after obtaining the institutional ethical approval in a dedicated COVID-19 hospital for a period of 4 months among 276 HCPs wearing grade 2 and 3 PPE kit. The survey questionnaire (Google Forms) was focused on collecting the subject's baseline data (age and gender), duty hours, and type of skin injury experienced due to PPE usage. Chi-square analysis was used to find the association of between dependent and independent variables, and an association was significant for P < 0.05.
RESULTS: 51.5% of subjects wore the PPE kit for 5 or more days/week during duty hours and 64.5% of subjects daily wore the PPE kit for 2 or more hours. 81.7% of subjects have suffered from skin injury after PPE usage. The most common symptom/sign for the skin injury that occurred was indentation and pain on the back of the ears (61.5%).
CONCLUSION: The frequent skin injuries due to PPE among the HCPs might make them anxious and reduce their morale at work place, so an effective preventive measure should be adopted.

Keywords: Facial itching, facial rashes, mask, protective clothing, skin chapping


How to cite this article:
Jaisinghani A, Gupta V, Gour N, Sharma MK. Skin damage due to personal protective equipment among health-care professionals in a dedicated COVID-19 hospital of tribal India. BLDE Univ J Health Sci 2022;7:134-40

How to cite this URL:
Jaisinghani A, Gupta V, Gour N, Sharma MK. Skin damage due to personal protective equipment among health-care professionals in a dedicated COVID-19 hospital of tribal India. BLDE Univ J Health Sci [serial online] 2022 [cited 2022 Aug 15];7:134-40. Available from: https://www.bldeujournalhs.in/text.asp?2022/7/1/134/348262



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 SARS, health-care professionals (HCPs) 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. HCPs 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 HCPs. Due to perceived risk of being infected, the HCPs generally restrict their social contacts. There is even a feeling of being isolated by their family members and friends because of their hospital work, which in turn presses them to be absent from work.[4]

Based on the evidence, especially while performing aerosol-generating medical procedures, adequate use of PPE is reasonable in controlling the infection.[5] It is shown in literature that the health-care workers who used masks, gowns, and handwashing had a lower likelihood of developing infection than those who did not use them.[6]

The use of PPE is essential to prevent the cross-transmission of the infection spread by respiratory droplets and indirect contact with fomites. The PPE comprises the equipment that protects the mouth, nose, eyes, ears, bare skin, and vulnerable parts, such as the head and hands from the deadliest infectious secretions of the patients. PPE has been linked to a variety of skin injuries, including pressure injuries, contact dermatitis, pressure urticaria, and exacerbations of preexisting skin diseases such as seborrheic dermatitis and acne.[7],[8]

The number of HCPs, including doctors and nurses, ranged from 270 to 290, and a majority of the recruitment of HCPs is still open, even though the college was established 3 years ago in this tribal district (Shahdol). The college is in evolving phase and has no postgraduate students, interns, or nursing students, so doctors and nursing staff have to look after the patients in the COVID-19 wards. With a limited number of HCPs, the duties are less rotated, which results in more hours of work and wearing the PPE kit while giving clinical and nursing care to the patients. Previous studies regarding skin injuries due to PPE kits (device-related pressure injury, moisture-associated skin damage, and skin tears) were conducted among patients, but there were few studies regarding skin injuries due to PPE among HCPs, which needed to be addressed urgently. We planned to conduct a descriptive study with the aim of estimating the prevalence of skin injuries and their types, finding the associations of related factors with the skin injuries, and analyzing the problems in the prevention and treatment of skin injuries among HCPs during the COVID-19 pandemic, which will provide a basis for developing strategies for preventing and treating skin injuries in the upcoming pandemics.


  Materials and Methods Top


Study setting and design

The investigator conducted a descriptive cross-sectional study over a period of 4 months (March 2021 to June 2021) in the dedicated COVID-19 hospital (DCH) at Government Medical College, Shahdol, Madhya Pradesh. GMC, Shahdol, was recognized the 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 HCPs 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 (email and phone) and which counted to 276 eligible subjects.

The sample size was calculated (n = 97) considering the proportion of HCP shaving 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 two-sided test), a = level of significance (0.05), P = prevalence (proportion – 50%), d = absolute allowable error (10%), and n = sample size, so all eligible study participants which counted to be 276 were included in the study using convenient sampling method.

Study subject inclusion criteria were as follows. (1) Those HCPs including doctors and nurses who cared for the suspicious and positive COVID-19 cases in intensive care unit (ICU), HDU, 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.

HCPs 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 it three times by consulting dermatologists, statistical experts, doctors, and nursing in-charges, and feedback was taken from some medical and nursing staff posted in DCH, Shahdol. It gathered baseline data (such as age, gender, occupation, marital status, having children at current stay, and staying alone at current stay); duty characteristics including PPE usage (such as 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, and work absenteeism due to skin injuries); and PPE-induced skin injury characterization, including preventive and treatment modalities taken for them (such as skin reactions related to mask, goggles/face shields, latex gloves, protective clothing, preventive measures taken to avoid skin injuries due to PPE, and treatment sought for the skin injury that 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] The survey link included an introductory paragraph outlining the aims and objectives of the study, followed by instructions to complete the questionnaire. It was also mentioned in the survey link that if any of the HCPs have any kind of PPE related skin injuries at present, they should 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 prior to 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 1-week period to respond to the questionnaire, and those who did not respond within the defined time (three or more consecutive reminders) were declared nonrespondents and were excluded from the study. The questionnaire was checked for completeness by the investigator himself, and incomplete questionnaires were excluded from the study. The subjects having skin injuries at present were examined by a dermatologist for the site, symptoms, signs, and systematic features of skin injury, and treatment was prescribed for them. The information pertaining to the subjects was kept anonymous and confidential. The study was performed following the Checklist for Reporting Results of Internet E-Surveys guidelines.

Data analysis

The data collected during the study were simultaneously entered into Microsoft Excel spreadsheet. The variables were coded in an appropriate manner. 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 were 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 of between dependent and independent variables. All tests (two-tailed) were performed at a 5% level of significance; thus, an association was significant if the P < 0.05.

Ethical consideration

All ethical issues were followed during the study. Participation was voluntary, and participants were allowed to withdraw from the study at any moment. No personal data was recorded. Participants were assured that all data collected were used only for the current study. The 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 Top


Out of total 276 study subjects, 262 subjects provided their responses for the questionnaire sent over social media. The mean age of study subjects was 30.7 ± 5.3 years. More than half of the study subjects were nurses (53.1%, 139/262). Nearly half of the subjects were unmarried (44.3%, 116/262). About two-fifth of subjects were staying alone at current place of stay (41.6%, 109/262) and more than one-third of subjects (35.5%, 93/169) had children at current place of stay [Table 1].
Table 1: Baseline characteristics of study subjects (n=262)

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During the amid of COVID-19 pandemic, the current institution was established as DCH, and lack postgraduate students, interns, and nursing students made all doctors and nursing staff from each department to be involved in the duty roster for COVID-19 ICU/wards, so about four-fifth of subjects (84.0%, 220/262) were confident in self-protection from COVID-19. Nearly two-fifth of subjects (64.5%, 169/262) were wearing the PPE kit for 2 or more hours per day during duty hours and 12.2% (32/262) of subjects reported absenteeism from duty hours due to PPE-induced skin injuries [Table 2].
Table 2: Duty characteristics of study subjects (n=262)

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More than four-fifth of subjects (81.7%, 214/262) reported that they have suffered from skin injury after PPE usage during duty hours [Table 3]. Skin injuries among subjects were mainly due to use of mask and Google/face shields (73.7%, 193/262) followed by use of latex gloves (66.0%, 173/262) and protective clothing (31.3%, 82/262). Commonly reported symptoms/signs of skin injuries were indentation and pain on back of ears (61.5%, 161/262), skin itching or rash (37.4%, 98/262), dry skin (35.9%, 94/262), and skin soaking in sweat (35.5%, 93/262).
Table 3: Characterization of personal protective equipment-induced skin injuries among study subjects (n=262)

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When subjects were asked whether they opted for any preventive measures to avoid skin injury due to PPE kit, nearly two-third of subjects (61.8%, 162/262) denied for such preventive measures being used. Only two-fifths of those who suffered from the skin injury (n = 214) sought treatment for it (41.1%, 88/214) [Table 4].
Table 4: Characterization of preventive and treatment modalities taken for skin injuries among study subjects (n=262)

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To find the association of reported skin injuries with the subject's various characteristics, the Chi-square analysis was applied [Table 5] and it was observed that skin injury was more frequent among subjects being nurses (86.3%, 120/139), married (84.9%, 124/146), having two or more members at current place of stay (85.0%, 130/153), wearing PPE kits for 5 or more days in a week during duty hours (87.3%, 117/134), and wearing PPE kits for 2 or more hours while on duty at DCH (86.4%, 146/169), but skin injuries were statistically significant associated with variables such as PPE kit wearing days/week, duration of PPE wearing/day, profession, and children at current stay of subjects (P < 0.05).
Table 5: Association of skin injuries with the baseline and duty characteristics of study subjects (n=262)

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  Discussion Top


The present study made an attempt to find out the skin injuries occurred after PPE kit usage among HCPs, and it was found that 81.7% 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 was observed, whereas the study by Navarro-Triviño et al. showed a lower prevalence of skin injury (12.7%) among subjects.[13],[14]

While analyzing more specifically which content of the PPE kit led to the most frequent skin injuries among HCPs, it was revealed that masks and goggles/face shields together led to skin injuries in around three-fourths (73.7%) of HCPs, followed by latex gloves and preventive clothing, which led to skin injuries among two-thirds (66.0%) and one-third (31.3%) of HCPs, respectively. In a study by Singh et al., goggles alone led to dermatoses in half of the subjects (51.92%), followed by N95 masks and face shields, causing dermatoses among two-thirds (66.0%) and one-third (31.3%) of HCPs, respectively.[15]

Indentation and pain on the back of the ears (61.5%) caused by masks or goggles, skin itching or rash (37.4%), skin soaking in sweat (35.5%), and dry skin (35.9%) caused by latex gloves, whether powdered or nonpowdered, were the most commonly expressed symptoms/signs of the skin injury that occurred, and this was consistent 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 COVID-19 pandemic, the present medical college was established as a DCH, and the rapid rise of cases during the first and second waves, along with a lack of postgraduate students, interns, and nursing students, made all HCPs from each department involved in the duty roster. In the present study, 84.0% of subjects had confidence in self-protection from COVID-19. Due to overburdened state, 64.5% of HCPs were wearing the PPE kit for 2 or more hours per day during duty hours, which was in coherence with the study by Agarwal et al., where 22.9% of health workers were wearing PPE for 6 or more hours, whereas a study by Jiang et al. showed that 85.7% of subjects were wearing PPE for more than 4 h.[9],[10] Due to continuous wearing hours of PPE kit, it caused skin injuries among 81.7% of doctors which made 12.2% of subjects absent from duty hours, and a review by Cook also approves the present study relevation.[17] A 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 number of health-care workers having discomfort while using PPE.[18]

The Chi-square analysis showed that PPE kit wearing days/week and duration of PPE wearing/day were significantly associated with the skin injury caused (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 HCPs was 30.7 ± 5.3 years, which reflects a quite young working health force in present evolving institution. Although the association was not found significant on Chi-square analysis, it was observed that skin injuries were quite frequent among subjects who were married (84.9%), and were not staying alone (85.0%), which shows that married and not staying alone HCPs were more cautious to use PPE kit to prevent spreading COVID-19 to others. A study by Kumar et al. showed that the 94.2% of subjects working in COVID-19 hospitals were concerned of infecting family members and a 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, 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 61.8% of subjects admitted that none of such preventive measures were considered by them.[7],[21],[22] Even among those who had skin injury, 58.9% of them lagged to sought treatment which was a very similar pattern observed in a 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 the author suggests to take a larger sample for such studies or to do multicentric study instead of single centric study as 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 HCPs in a tribal district of India. Along with that, subjects with skin injuries were treated by a dermatologist during and after study period. Apart from this, the 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 Top


In this study, it was found that 81.7% of subjects had suffered from skin injuries while using the PPE and corresponding care and preventive measures required among health-care workers caring for COVID19 patients during duty hours. Hence, 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.



 
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Chen 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.  Back to cited text no. 3
    
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Goulia 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.  Back to cited text no. 4
    
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Darlenski R, Tsankov N. COVID-19 pandemic and the skin: What should dermatologists know? Clin Dermatol 2020;38:785-7.  Back to cited text no. 7
    
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Gheisari 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.  Back to cited text no. 8
    
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Jiang 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.  Back to cited text no. 9
    
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Agarwal A, Agarwal S, Motiani P. Difficulties encountered while using PPE kits and how to overcome them: An Indian perspective. Cureus 2020;12:e11652.  Back to cited text no. 10
    
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Lan 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.  Back to cited text no. 13
    
14.
Navarro-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.  Back to cited text no. 14
    
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Singh 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.  Back to cited text no. 15
    
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Hu 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.  Back to cited text no. 16
    
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21.
Bishopp 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.  Back to cited text no. 21
    
22.
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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