The plastic pandemic: can the NHS' response to covid-19 reduce the environmental impact?

We agree with the views of Dr. Zhang and others. In their concern about the catastrophic environmental impact of disposable personal protective equipment (PPE) [1].

According to the law, PPE “should be the last line of defense”; occupational environmental control and ventilation design optimization of inhaled hazardous substances should be mandatory to reduce the spread of COVID-19. However, the precautionary principle must be applied [2], so from now on, PPE is likely to become the backbone of the healthcare field.

The World Health Organization has declared that climate change is one of the greatest risks to human health. They predict that between 2030 and 2050, 250,000 people will die every year due to climate change, partly due to infectious diseases. [3] Policymakers and NHS stakeholders must take this into consideration when investing in PPE.

However, Dr. Zhang et al. It states that “one-time use PPE is essential to prevent infection and control disease in the healthcare environment [1]”, but this is not the case.

The reusable option is not only better for the environment, but also a widely available option, which is superior to the wearer and the system in which it works on multiple levels.

For example, take the reusable FFP3 respirator; this form of respiratory protection can be easily decontaminated. Since April 2020, multiple health committees across the UK have adopted this smart approach. You can easily develop standard operating procedures (SOP) [4] and use autoclave, ultraviolet light [5] or immersion in 70% alcohol [6] to purify reusable PPE -8], depending on the manufacturer’s recommendations, Microbiological protocol and locally available cleaning equipment. In the UK, some factories have manufactured reusable respiratory protection devices, while others can be easily and quickly retrofitted to facilitate this. Local procurement will reduce the carbon footprint delivered to the UK's first-line services, and has the added benefit of reducing dependence on unstable international supply chains and increasing investment in the local economy during times of crisis. Some countries have conducted a system-wide review of the manufacturing, procurement and supply of personal protective equipment after the Middle East Respiratory Syndrome epidemic, and chose to invest in the manufacture of high-quality personal protective equipment within their borders, thus ensuring the flexibility of the supply chain[9] .

Reusable full-face and half-face respirators provide the best respiratory protection for health or social care workers; the protection is far better than disposable FFP3 masks [10]. Except for one-time use, surgical masks cannot protect the wearer from SARS-CoV-2 inhalable aerosol particles, which are produced when the patient breathes, speaks, or coughs. With a wider seal (10-20 mm) [10], reusable respirators achieve the air-tight seal required by more people, including those with small faces who fail the suitability test of disposable masks. Since women and Asian races have the highest failure rates in fit tests [12], the improved fit provided by the reusable option is particularly important. Women account for 75% of the NHS labor force [13], and the mortality rate of COVID-19 among blacks and Asians is significantly higher [14]. A wider, face-fitting seal also makes reusable masks more comfortable to wear.

Reusable respiratory protection has huge economic advantages; staff facing patients usually need to change their masks multiple times a day. The cost of a disposable mask is about £5, while the cost of a reusable FFP3 respirator is as low as £15, and the filter element needs to be replaced after each pandemic wave [15] (100 pairs of filter elements are about £5-10) or According to specific manufacturer and local infection control instructions. Compared with disposable masks, the use of reusable FFP3 masks can save 84% of the cost per year [16]. The use of reusable respiratory protection devices, such as electric air purifying respirators (PAPR) or reusable full face masks, eliminates the need for time-consuming and expensive suitability testing tasks. The suitability test removes employees from their important roles for at least 30 minutes and disposes of valuable PPE resources in the process. By January 2021, the British government has spent approximately £15.2 billion on PPE for the COVID-19 pandemic.[17] Most of these are for one-time use and will now be burned in landfills, oceans or the atmosphere. [17] 18].

The British Medical Association (BMA) and the Royal College of Nursing (RCN) require the use of FFP3 respiratory protection devices to protect all front-line workers from the airborne transmission of COVID-19 [19 20]. Front-line workers are very keen to use the reusable FFP3 respirator. Med Supply Drive UK (charity number 1190337) found that 95% of the 487 frontline employees surveyed wanted to use reusable FFP3 respirators. Include feedback;

"Yes. There is already. This is great. Very comfortable. I don't think there will be a shortage of masks in the future. It is also much better for the environment."

"I didn't pass the suitability test, so I got a half-mask respirator. It worked well for two years, and the filter lasted for six months. In the long run, it may also be cheaper."[21]

Public Health England, Public Health Wales, Scottish Health Protection, Public Health Service, Royal College of Medicine and National Health Service have recommended the use of reusable FFP3 respirators [22]. The Federation of British Surgeons issued a statement in support of reusable PPE[23], and the chairpersons of all surgical specialists and anesthesiologists (FSSA) in the UK support the use of reusable respiratory protection devices. However, most health and social care workers still receive low-quality disposable PPE.

Therefore, reusable PPE is not only a solution to the destructive effects of continued use of disposable PPE on the environment, but in the long run, it is also highly safe, economical and practical. The reusable FFP3 respirator is a solution that provides health and social care workers with the best life-saving equipment they want, need and deserve.

MedSupplyDrive UK is a charity (charity number 1190337) established by volunteer healthcare professionals, medical students and allies. They are committed to sourcing, producing and advocating high-quality, sustainable personal protective equipment to protect British health and social care workers from COVID-19. MedSupplyDrive UK supports health and social care workers requesting the use of reusable FFP3 respirators in their workplaces so that they can safely care for patients. MedSupplyDrive UK is launching a campaign to protect workers by providing free reusable FFP3 respirators. For more information, please visit www.medsupplydrive.org.uk. Or email: info@medsupplydrive.org.uk.

References 1. Zhang EJ, Aitchison LP, Phillips N, etc. Protect the environment from plastic PPE. BMJ 2021;372:n109 doi: 10.1136/bmj.n109 [Online publication first: Epub date]|. 2. British H, Staff SE, Health GB, etc. Respiratory protective equipment at work: A practical guide: HSE book, 2013. 3. World Health Organization. Climate change and health. Secondary Climate Change and Health 2018. https://www.who.int/news-room/fact-sheets/detail/climate-change-and-heal.... 4. Bessesen MT, Adams JC, Radonovich L, etc. Al. Health care workers sterilizing reusable elastic respirators: feasibility study and development of standard operating procedures. American Journal of Infection Control 2015;43(6):629-34 5. Department of Homeland Security. Disinfection and reuse of personal protective equipment Re-disinfection and reuse of personal protective equipment in 2020. https://www.dhs.gov/sites/default/files/publications/respiratoryprotecti.... 6. Sundström. Pandemic influenza kit, SR 100. Second pandemic influenza kit, SR 100 2020. https://www.srsafety.com/pub/media/wysiwyg/srsaftey/CompCentre/Articles/.... 7. 3M. Respiratory protection against biological hazards in the air, technical bulletin. Secondary Respiratory Protection from Biological Hazard Exposure in the Air, 2020 Technical Bulletin. https://multimedia.3m.com/mws/media/409903O/respiratory-protection-again.... 8. 3M. Purification of 3M filter mask respirators (such as N95 respirators) in the United States-matters needing attention. Secondary decontamination of 3M filter mask respirators (such as N95 respirators) in the United States-Precautions for 2020. https://multimedia.3m.com/mws/media/1824869O/ Decontamination-Methods-for... 9. Gereffi G. Regarding global value chains, what has the COVID-19 pandemic taught us? The situation of medical supplies. Journal of International Business Policy 2020;3(3):287-301 doi: 10.1057/s42214-020-00062-w [Online publication first: Epub date]|. 10. Gawn J, Clayton M, Makison C, etc. Evaluate the protection of surgical masks against influenza bioaerosols: the overall protection of surgical masks compared to filter mask respirators. Health Safety Exec 2008 11. Douglas J, McLean N, Horsley C, etc. COVID-19: Smoke testing of surgical masks and respirators. Occupational Medicine 2020;70(8):556-63 12. Regli A, Sommerfield A, von Ungern-Sternberg B. The role of N95/FFP2/FFP3 mask suitability testing: a narrative comment. Anesthesia 2021;76(1):91-100 13. Bissett J. PPE masks are generally not suitable for women and Asian healthcare workers. Secondary PPE masks are generally not suitable for women and Asian healthcare workers 2020. https://www.dental-nursing.co.uk/news/ppe-respirator-masks-often-fail-to... 14. Office country statistics . Coronavirus (COVID-19) related deaths of all ethnicities in England and Wales: March 2, 2020 to May 15, 2020. Coronavirus (COVID-19)-related deaths of all ethnicities in England and Wales: March 2, 2020 to May 15, 2020. https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarri .... 15. 3M. 3M™ reusable half-mask for the healthcare industry. The secondary 3M™ reusable half-mask used in the healthcare industry in 2020. https://www.3m.co.uk/intl/uk/ohes/segments/healthcare/(9666a)OH_ReusableTechBulletin_lft.pdf 16. Iacobucci G. Promote reusable PPE: five minutes. .. He Moli. BMJ 2021;372:n270 doi: 10.1136/bmj.n270 [Online publication first: Epub date]|. 17. https://www.instituteforgovernment.org.uk/publication/whitehall-monitor-.... 18. Rizan C, Reed M, Bhutta MF. In the first six months of the COVID-19 pandemic, the environmental impact of personal protective equipment provided for health and social care services in England. medRxiv 2020:2020.09.21.20198911 doi: 10.1101/2020.09.21.20198911[Online release first: Epub date]|. 19. Tonkin T. called for the enhancement of PPE. The secondary appeal for enhanced PPE in 2021. https://www.bma.org.uk/news-and-opinion/call-for-enhanced-ppe. 20. Royal College of Nursing. Public Health England must urgently review whether current PPE and ventilation guidelines are still adequate. The secondary public health agency in England must urgently review whether the current PPE and ventilation guidelines are still adequate. 2021. https://www.rcn.org.uk/news-and-events/news/uk-higher-level-ppe-protect-.... 21. Medsupplydrive. Medical supply drive. Secondary Medsupplydrive in 2021. https://www.medsupplydrive.org.uk/news. 22. Public Health England. PPE recommended for medical staff by secondary nursing inpatient clinical environment, NHS and independent departments. Secondary care hospitalized clinical environment, NHS and independent department recommended secondary PPE for medical staff in 2020. https://associationofbreastsurgery.org.uk/media/252021/t1_poster_recomme.... 23. Federation of British Surgeons. New research: The current PPE is not suitable for use. Minor new research: Current PPE is not suitable for 2020 goals. https://www.cbsgb.co.uk/news/36/new_study_current_ppe_not_fit_for_ purpose.

Conflict of interest: no conflict of interest