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By Bruce Farber and Aradhana Khameraj March 4, 2022
E very time we enter a Covid patient’s room, we first don gloves, and a disposable gown. When we come out of the room, we remove that gear and put it in one of the many bulging disposal bags lining the halls of our hospital. We go through the same process for the next patient, as do health care workers across the country and around the world. It would not be uncommon for this to happen 30 times a day for each patient as nurses, physicians, aids, and others provide care.
Multiply our actions by the thousands of health care workers who see patients every day, and the nearly 800 days since Covid-19 was declared a public health emergency in the U.S. and around the world, and the scope of the disposal problem becomes huge.
Donning and doffing personal protective equipment (PPE) made sense in early 2020, when Covid-19 began its relentless march around the globe. It was prudent to institute various infection-control practices because no one knew then how SARS-CoV-2, the virus that causes Covid-19, was transmitted.
As the pathogen spread, health care workers were often infected with it. In our health care system, Northwell Health, more than 20 of our colleagues died of Covid-19 during the first three months of the pandemic. Frantic attempts to obtain enough personal care equipment to protect front-line workers became a major responsibility of health systems across the country.
Given all the uncertainty about viral transmission, the Centers for Disease Control and Prevention and the World Health Organization conservatively assumed the virus could be transmitted by droplets, aerosols, or direct contact. The transmission of pathogens spread by droplets and aerosols can be prevented by using masks and eye protection, which is what health care workers have traditionally used when seeing patients who have or might have influenza. Gowns, gloves, and other gear are needed to prevent the transmission of pathogens spread by direct contact.
Early in the pandemic, people were being urged to disinfect everything they touched, including their packages. Hand sanitizers are still present in virtually every public venue, including schools. New York City spent hundreds of millions of dollars disinfecting the subways each night. Many other public venues still have special cleaning protocols.
Current guidelines from the CDC and WHO require health care workers who provide direct care to patients to wear masks, protective eyewear or face shields, gowns, and gloves. Many health care workers have also requested to use scrubs, shoe covers, and bouffant hair coverings, items that were once supplied only to those working in operating rooms.
Gowns, coverings, and gloves are to be replaced between each patient contact.
National data on the use of personal protective equipment are hard to come by. Our health system alone, which is the largest provider of health care in New York State, used more than 2.5 million isolation gowns a month during the first wave of Covid-19 in March and April 2020. During the Omicron wave of December and January, the number had dropped to about 800,000 per month, but that is still twice the volume used before the pandemic. There were also large increases in the use of scrubs, gloves, and bouffants.
Similar patterns have occurred in hospitals and nursing homes across the country.
Health care systems have spent billions of dollars acquiring personal protective equipment. But there’s a hidden cost that has largely gone unnoticed: All of these items are disposable, and medical waste is not recycled. Disposing this gear is costly, and damages the environment. The Environmental Protection Agency estimated that about 3 million tons of medical waste was generated yearly in the United States alone prior to the pandemic. On February 1, 2022, the WHO issued a report on the need to deal with the critical problem of medical waste and its adverse impact on the environment. It highlights the expense and climate implications of the incineration of the mostly plastic waste.
Given what is known today about the transmission of SARS-CoV-2, the CDC and WHO have failed to update their two-year-old policies on protective personal equipment that add to the waste problem. Although the CDC guidelines do not carry the force of law, states and medical centers feel an obligation to follow them.
Having taken care of hundreds of Covid-19 patients, we would have no concern about entering a patient’s room without an isolation gown, because this infection is transmitted through the air via droplets and aerosols, not by touching a contaminated surface. Although hand washing is always an important part of infection prevention efforts, contamination of one’s clothes, hair and shoes have never been shown to be a problem.
It makes no sense for health care workers to gown up to go into the rooms of Covid-19 patients they often have fleeting contact with.
The CDC also needs to dial back on its messaging that cleaning surfaces and using hand sanitizer will decrease the risk of Covid transmission, when there is no evidence to support either.
As Covid moves from a pandemic to an endemic infection, it is important to communicate accurately what really is important in preventing spread. There is no doubt that proper ventilation, the use of masks, and most importantly vaccines can prevent spread both inside and outside of hospital settings.
Using unnecessary garb to interrupt a theoretical mechanism of spread is not worth the cost and damage to the environment and erodes public confidence in the CDC and its expertise.
Bruce Farber is an infectious disease physician, chief of public health and epidemiology at Northwell Health, and chief of infectious diseases at North Shore University Hospital and LIJ Medical Center. Aradhana Khameraj is a registered nurse and director of infection prevention at North Shore University Hospital.
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