A day after the Union Health Ministry advocated for the rationing of personal protection equipment (PPEs), the All India Institute of Medical Sciences (AIIMS) has issued a circular on Tuesday stating that protective N-95 masks will be provided to all healthcare workers involved in direct patient care.

However, medical staff have complained that there may have been “over-rationing of the masks”, with the circular from AIIMS stating that it will provide only five N-95 masks each to doctors, nursing officers, technical staff, security guards and maintenance staff for 20 days. The circular states that the issued N-95 masks are to be disinfected by individual users and re-used at least four times each, thus stretching their use for over half a month.

“It is imperative that in accordance with evidence-based scientific literature these N-95 masks are to be disinfected by individual users [by keeping them in open after use or by other methods] and reused at least four times each,” states the circular.

Following the circular on masks, AIIMS also issued guidelines for reuse of PPEs which noted that the COVID-19 pandemic has strained resources tremendously in the healthcare setting and that one of the most urgent issues is the fast depletion of PPEs used in the care of patients.

However, it warns that while decontamination and reuse of PPEs may extend existing on-hand supplies, currently decontamination of PPEs for purposes of reuse is not recommended.

Contrary guidelines

The circulars have sparked concern among staff at the premier medical institution. “Doctors are puzzled by what the hospital administration is telling us to do. They are stating that we should reuse a product multiple times, disinfect it by ourselves but then [also] issuing guidelines that clearly state that is not recommended during COVID-19,” said a senior physician at AIIMS, Delhi.

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“It has very clearly said that given the uncertainties on the impact of decontamination on respirator performance, these should not be worn by HCWs [healthcare workers] when performing or present for an aerosol generating procedure. The methods available for disinfection are only considered as extraordinary, last-resort methods in the event of imminent shortages of PPE,” the physician added.

As per guidelines from the U.S. Centers for Disease Control and Prevention, N-95 masks can be reused till they are functional, which means that the N-95 respirator maintains its physical integrity and when used properly, provides protection (exposure reduction) consistent with the assigned protection factor for this class of respirator. But when reusing, it is preferred that health professionals use a cleanable face shield over the mask, the guidelines say.

WHO guidance

The World Health Organisation (WHO) in its latest interim guidance issued on Tuesday on use of face masks during COVID-19 pandemic said: “Health care workers should wear a medical mask when entering a room where patients with suspected or confirmed COVID-19 are admitted and use a particulate respirator at least as protective as a U.S. National Institute for Occupational Safety and Health certified N-95, European Union standard FFP2, or equivalent, when performing or working in settings where aerosol-generating procedures, such as tracheal intubation, non-invasive ventilation, tracheotomy, cardiopulmonary resuscitation, manual ventilation before intubation, and bronchoscopy are performed.”

“Wearing a medical mask is one of the prevention measures that can limit the spread of certain respiratory viral diseases, including COVID-19. However, the use of a mask alone is insufficient to provide an adequate level of protection, and other measures should also be adopted,” notes the WHO.

The AllMS Resident Doctors’ Association had also appealed to Prime Minister Narendra Modi in a letter on Monday urging him to instruct authorities to withdraw punishment of doctors who took to social media for highlighting lack of PPEs.