Limiting the use of personal protective equipment (PPE) to only N95 respirators late in the COVID-19 pandemic in Singapore healthcare facilities kept staff safe, reduced plastic waste and carbon emissions, and lowered related costs, a JAMA Network Open study concludes.
The National Centre for Infectious Diseases in Singapore–led quality-improvement study evaluated the use of PPE and monthly COVID-19 rates among medical, allied, ancillary, and administrative staff at Tan Tock Seng Hospital and in the community before (October 2021 to September 2022) and after (October 2022 to September 2023) PPE de-escalation.
Some PPE guidelines haven't changed
When the COVID-19 pandemic began, the World Health Organization (WHO) released PPE guidelines for healthcare personnel (HCP) caring for patients with SARS-CoV-2 infections. PPE included protective gowns, face shields, gloves, and medical masks, with the use of N95 respirators during aerosol-generating procedures.
Before the WHO declared the end of the public health emergency and a reversion to standard infectious-disease management in early 2023, the Singapore Ministry of Health updated its national PPE recommendations for HCP caring for patients with confirmed or suspected COVID-19, advising the use of N95 respirators alone from September 27, 2022, onward.
But guidelines on PPE from the US Centers for Disease Control and Prevention (CDC) still also recommend the use of gowns, gloves, and eye protection, and the European Centre for Disease Prevention and Control (ECDC) also advised gowns and gloves when there is a risk of contact with body fluids.
Averted 276,000 pounds of waste from landfill
The average monthly HCP roster was 10,774 before de-escalation and 11,099 after. Staff-to-community COVID-19 rates were similar (median community rate, 2.6 before and 1.5 after de-escalation).
Limiting PPE to N95 respirators was linked to a 1-year savings of 440,532 gowns, 398,681 kilograms (kg; 878,942 pounds) of carbon dioxide equivalent (CO2e) in emissions, 66,080 kg (135,681 pounds) of plastic waste, and about $453,748 in Singapore dollars ($333,970 US) in healthcare costs.
"Using the conversion factors provided by the Environmental Protection Agency, 398,681 kg CO2e equals the emissions from 169,817 liters [44,861 gallons] of gasoline consumed," the authors wrote. "It also equals the greenhouse gas emissions avoided by recycling 138 tons (approximately 125,191 kg [276,000 pounds]) of waste instead of landfilling and is equivalent to the carbon sequestered by 6,592 tree seedlings grown for 10 years."
After PPE de-escalation, the number of gowns used per patient-day fell by 10.6 in the general wards, 20.9 in the intensive care unit, and 11.04 overall.
Pandemic drove dramatic rise in healthcare waste
The pandemic sparked a steep rise in healthcare waste. For example, in Wuhan, China, medical waste spiked by nearly 400%, from 50 tons per day prepandemic to 247 tons per day at the pandemic peak, the researchers noted.
The pandemic also intensified environmental pollution, with PPE disintegrating into microplastics and microfibers, which persist in ecosystems for years, accumulating in river water and sediments.
"Sterilization plants in Madrid, Spain, operated at full capacity processing 50 tons per day, while Catalonia managed 1,200 tons of health care waste between mid-March to mid-April 2020, a 300% to 350% rise from the baseline of 275 tons per month," they wrote. "In Bangladesh, approximately 14,500 tons of health care waste were generated at the pandemic’s peak."
"The pandemic also intensified environmental pollution, with PPE disintegrating into microplastics and microfibers, which persist in ecosystems for years, accumulating in river water and sediments," they added.
Moving toward tailored approaches
"The disposal of polypropylene PPE waste during the pandemic has led to an environmental hazard, with over 4 million metric tons of PPE waste and microplastic byproducts entering the environment since the pandemic's onset," the researchers wrote. "Polypropylene, resistant to biological degradation, can remain in the natural environment for up to 450 years."
Exploring alternatives to single-use plastic gowns, such as reusable gowns or those made from more sustainable materials, is essential.
They said that eliminating unneeded PPE can improve interactions between HCP and patients and lessen the negative psychological effects on patients without raising the risk of disease transmission.
"Exploring alternatives to single-use plastic gowns, such as reusable gowns or those made from more sustainable materials, is essential," they wrote. "Given the widespread availability of effective vaccines, decent levels of herd immunity, and the generally milder illness with current circulating Omicron variants, it is timely that health authorities reexamine their PPE recommendations for COVID-19."
In a related commentary, Meghana Gadgil, MD, MPH, of the University of California, and Preeti Mehrotra, MD, MPH, of Beth Israel Deaconess Medical Center, said the study findings reveal an opportunity for healthcare systems to increase investment in research into disease transmission dynamics and in expanding implementation of engineering controls.
"By moving beyond a one-size-fits-all approach to PPE use, health care facilities can better balance infection prevention with environmental responsibility," they wrote. "By integrating evidence-based transmission control with sustainable practices, health care systems can protect both patients and planet. This dual commitment to safety and sustainability will define resilient health care for generations to come."
