Heat Stress and Thermal Perception amongst Healthcare Workers during the COVID-19 Pandemic in India and Singapore

Impact of Heat and Mitigation Strategies on Healthcare Professionals: A Scoping Review

BACKGROUND

Rising global temperatures and increased use of personal protective equipment has led to increased risk of heat stress amongst healthcare professionals. This review synthesizes recent research on the impact of heat and heat mitigation strategies on healthcare professionals across disciplines and settings.

METHOD

Databases were systematically searched using keywords and data from included studies were extracted for content analysis.

RESULTS

Among 15 eligible studies, 13 investigated the impact of heat stress on healthcare professionals. Six investigated mitigation strategies. Most studies utilized survey methodology and were related to the use of personal protective equipment during the recent pandemic. Large proportions of healthcare professionals reported high levels of thermal discomfort and preferred a cooler temperature in the workplace. The most commonly reported heat strain symptoms included sweating, fatigue, thirst, and poor or reduced concentration. Investigation of mitigation strategies has thus far focused on individual strategies with little insights gained into organizational support or heat policy.

CONCLUSIONS

Supporting healthcare professionals to manage the impact of heat stress has received little attention in the literature. Mitigation strategies have thus far focused predominantly upon individual strategies. Future studies should adopt a more comprehensive approach to investigating healthcare professional's experiences, investigating all levels of controls.

Occupational heat stress and its health impacts- an overview of research status and need for further research in Southeast Asia with special emphasis on mitigation strategies in North East India

The Intergovernmental Panel on Climate Change, IPCC predicts that hot seasons will get even hotter due to global climate change. There exists a critical dependence of human metabolic processes on temperature. Changes in thermal balance therefore, have an adverse effect on health because they raise body temperature, cause excessive sweating, and accelerate the rate of dehydration. Different nations and professional groups use different techniques to measure heat strain. This paper aims to review previous research conducted in the area of heat strain due to heat exposure among workers in Southeast Asia and also to profile mitigation strategies in North East India. Studies conducted between the years 2011 to 2023 in the evaluation of the health impacts of occupational heat stress were searched systematically using several sources of databases like PubMed, Google Scholar, Science Direct, Web of Science, Scopus, etc. It was noted that a greater proportion of previous research on evaluating physiological effects was carried out in controlled environments as opposed to real-world field settings. While such studies give us valuable insights into the relationship, applying the same methodology in the workplace may not be feasible. In India, very few research has been carried out on workplace heat stress, and even fewer have been done in North East India using physiological indicators. North East India is also affected by global climate change leading top more hotter days than before. The region of Northeast India, particularly Guwahati (Assam), has recently seen extreme heat waves during the sweltering summer months. With less literature available in this geographical location, studies with actual field-based settings are much needed to understand the occupational health impacts in this region. This review can formulate a suitable methodology for assessing the health impacts in working environment. This can also help the local health professionals to recognize the heat strain parameters that are acceptable worldwide, and use as pertinent indicators to scrutinize worker's health and develop preventive agendas as climate change advances.

Effects of Heat Exposure and Ice Slurry Ingestion on Risk-Taking Behavior in Healthcare Workers

PURPOSE

Healthcare workers (HCWs) wearing personal protective equipment (PPE) experience physiological strain that can impair motor and psychological functions, potentially affecting patient care. We assessed the effects of heat exposure on maximal strength and risk-taking behavior among PPE-wearing HCWs and the efficacy of ice slurry to alleviate adverse effects.

METHODS

Seventeen HCWS completed two experimental trials in a crossover design, consuming 5 g·kg -1 of body mass of ambient drink (AMB) or ice slurry (ICE) before donning PPE and undergoing 2 h of simulated decontamination exercise (wet-bulb globe temperature (WBGT): 25.9°C ± 0.8°C, PPE microenvironment WBGT: 29.1°C ± 2.1°C). Body core temperature ( Tc ), heart rate (HR), chest skin temperature ( Tsk ), ratings of perceived exertion (RPE), thermal sensation (RTS), maximal voluntary contraction (MVC), risk-taking behavior (balloon analogue risk-taking task (BART)), and salivary cortisol were assessed.

RESULTS

Predrinking to postdrinking ∆ Tc was greater in ICE (-0.2°C ± 0.1°C) than AMB (-0.0°C ± 0.1°C, P = 0.003). Post-drinking RTS was lower in ICE (2.7 ± 1.2) than AMB (4.1 ± 0.4, P < 0.001). ICE and AMB had similar Tc and HR (both P > 0.05), but Tsk was lower in ICE than AMB ( P = 0.049). A lower MVC (30.3 ± 6.7 vs 27.4 ± 4.9 kg, P = 0.001) and higher BART-adjusted total pump count (472 ± 170 vs 615 ± 174 pumps, P = 0.017) was observed pretrial to posttrial in AMB but absent in ICE (both P > 0.05). Salivary cortisol was similar between trials ( P = 0.42).

CONCLUSIONS

Heat-exposed PPE-wearing HCWs had impaired maximal strength and elevated risk-taking behavior. This may increase the risk of avoidable workplace accidents that can jeopardize HCWs and patient care. Ice slurry ingestion alleviated these heat-related impairments, suggesting its potential as an ergogenic aid.

Prevalence of occupational heat stress across the seasons and its management amongst healthcare professionals in the UK

Occupational heat stress (OHS) is an issue in healthcare facilities (HCFs) in the United Kingdom (UK). The aims of this study were to evaluate perceived levels of OHS during two seasons and its perceived consequences on healthcare professionals (HCPs) and to assess the efficacy of heat stress management (HSM) policies. An anonymous online survey was distributed to HCPs working in HCFs in the UK. The survey returned 1014 responses (87% women). Descriptive statistics and content analysis of survey data identified that OHS in HCFs is frequently experienced throughout the year and concerned most HCPs. Over 90% perceived OHS impairs their performance and 20% reported heat-related absenteeism. Awareness of HSM policies was poor and 73% deemed them not adequate. To help reduce the financial loss and impact on staff performance, health and well-being and patient safety, it is recommended that revisions and widespread dissemination of HSM policies are made.

Prevalence of headaches in healthcare workers while using personal protective equipment during the COVID-19 pandemic: a systematic review and meta-analysis

OBJECTIVES

During the COVID-19 pandemic, healthcare workers (HCWs) are at a serious risk of contracting this virus. Therefore, they should use personal protective equipment (PPE) to protect themselves. Long-term use of these devices has led to many side effects, including headaches. This study investigated the prevalence of headaches related to using PPE in HCWs during the COVID-19 pandemic.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Embase, PubMed, Scopus and Web of Science databases were searched from December 2019 to February 2023.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

All cross-sectional studies that investigated the prevalence of headache complications caused by PPE were included.

DATA EXTRACTION AND SYNTHESIS

Two researchers reviewed the articles separately and independently. The Appraisal Tool for Cross-Sectional Studies was used to address study design quality and the risk of bias in cross-sectional studies. The heterogeneity of the studies was checked with the I2 statistic, and due to the high heterogeneity, the random effects model was used for synthesis. Data were analysed using Comprehensive Meta-Analysis software V.3.3.70.

RESULTS

Out of 3218 articles retrieved for all side effects, 40 were eligible for this meta-analysis. The prevalence of headaches related to the use of PPE in these 40 studies, with a sample size of 19 229 people, was 43.8% (95% CI 43.1% to 44.6%, I2=98.6%, p<0.001). Based on the meta-regression results, no significant relationship was observed between the prevalence of headaches and variables such as year of publication, study location, sample size and quality of studies.

CONCLUSION

Headache is one of the common side effects of PPE, which can interfere with HCWs' performance. It is suggested that manufacturers improve the quality of their equipment while healthcare managers should equip and train staff adequately to minimise side effects, ensuring health and enhanced service delivery.

PROSPERO REGISTRATION NUMBER

CRD42021264874.

Assessment of subjective well-being of healthcare workers in response to heat and personal protective equipment under controlled conditions using a standardized protocol

BACKGROUND

Due to climate change, the increasing frequency of hot summer days and heat waves can result in occupational heat strain, especially in non-air-conditioned workplaces. Healthcare workers (HCW) engaged in patient care are particularly affected, as they are additionally exposed to physical stress. The use of personal protective equipment (PPE) can aggravate heat strain in HCW. This study aimed to examine the subjective well-being of HCW when exposed to heat and PPE under controlled conditions.

METHODS

This study was designed as a randomized crossover trial. Participants performed standardized healthcare tasks in a climatic chamber for approximately 3.5 h at different indoor temperatures (22 °C and 27 °C) and varied working conditions (with or without PPE). The effects on participants' subjective well-being, encompassing thermal, physiological and psychological stress were assessed using a customized questionnaire.

RESULTS

Heat had a greater effect than PPE on thermal, physical and psychological stress. Conversely, PPE had a greater effect on physical demand and effort. For the majority of outcomes, combined exposure to heat and PPE resulted in the highest perceived discomfort. Furthermore, the participants reported increased sweating and other discomforts when working at elevated temperatures or with PPE.

CONCLUSIONS

In this study, heat and PPE, but particularly the combination of both factors, were identified as unfavorable working environments. Although the trials were conducted in a controlled environment, the outcomes provide valuable information about the effect of heat and PPE on HCW in a real-life setting. Furthermore, the design used in this study can be beneficial in evaluating the effect of mitigation strategies.

Effects of wearing medical gowns at different temperatures on the physiological responses of female healthcare workers during the COVID-19 pandemic

BACKGROUND

Using medical gowns with high protection against COVID-19 among healthcare workers (HCWs) may limit heat exchange, resulting in physiological challenges.

OBJECTIVE

This study aimed to compare the physiological and neurophysiological responses of female HCWs when using two typical medical gowns at different temperatures during the COVID-19 pandemic.

METHODS

Twenty healthy female HCWs participated in this study. Participants wore two types of medical gowns: Spunbond gown (SG) and laminate gown (LG). They walked on a treadmill in a controlled climate chamber for 30 minutes at three different temperatures (24, 28, and 32°C). Heart rate (HR), skin surface temperature (ST), clothing surface temperature (CT), ear temperature (ET), blood oxygen percentage (SaO2), galvanic skin response (GSR), and blood pressure were measured before and after walking on a treadmill. The study's results were analyzed using SPSS26.

RESULTS

The study found that LG led to an average increase of 0.575°C in CT compared to SG at the same temperatures (P < 0.03). The average HR increased by 6.5 bpm in LG at 28°C compared to SG at a comfortable temperature (P = 0.01). The average ET in SG and GSR in LG at 32°C increased by 0.39°C and 0.25μS, respectively, compared to the comfortable temperature (P < 0.02).

CONCLUSION

The study recommends maintaining a comfortable temperature range in hospitals to prevent physiological challenges among HCWs wearing medical gowns with high protection against COVID-19. This is important because using LG, compared to SG, at high temperatures can increase HR, ET, CT, and GSR.

Water-blocking Asphyxia of N95 Medical Respirator During Hot Environment Work Tasks With Whole-body Enclosed Anti-bioaerosol Suit

Background

During hot environment work tasks with whole-body enclosed anti-bioaerosol suit, the combined effect of heavy sweating and exhaled hot humid air may cause the N95 medical respirator to saturate with water/sweat (i.e., water-blocking).

Methods

32 young male subjects with different body mass indexes (BMI) in whole-body protection (N95 medical respirator + one-piece protective suit + head covering + protective face screen + gloves + shoe covers) were asked to simulate waste collecting from each isolated room in a seven-story building at 27-28°C, and the weight, inhalation resistance (Rf), and aerosol penetration of the respirator before worn and after water-blocking were analyzed.

Results

All subjects reported water-blocking asphyxia of the N95 respirators within 36-67 min of the task. When water-blocking occurred, the Rf and 10-200 nm total aerosol penetration (Pt) of the respirators reached up to 1270-1810 Pa and 17.3-23.3%, respectively, which were 10 and 8 times of that before wearing. The most penetration particle size of the respirators increased from 49-65 nm before worn to 115-154 nm under water-blocking condition, and the corresponding maximum size-dependent aerosol penetration increased from 2.5-3.5% to 20-27%. With the increase of BMI, the water-blocking occurrence time firstly increased then reduced, while the Rf, Pt, and absorbed water all increased significantly.

Conclusions

This study reveals respirator water-blocking and its serious negative impacts on respiratory protection. When performing moderate-to-high-load tasks with whole-body protection in a hot environment, it is recommended that respirator be replaced with a new one at least every hour to avoid water-blocking asphyxia.

Literature review of physiological strain of personal protective equipment on personnel in the high-consequence infectious disease isolation environment

BACKGROUND

Heat strain and dehydration can affect an individual's physical and mental performance. The purpose of this review was to examine the literature for the impact of heat strain on health care workers (HCWs) who care for patients with high-consequence infectious diseases (HCIDs) while wearing personal protective equipment (PPE), discuss the risks of impaired safety caused by heat strain and dehydration in HCID environments, identify attempts to combat PPE-related heat strain, recognize limitations, and provide suggestions for further research.

METHODS

A literature search was performed in PubMed or MEDLINE and Google Scholar. Authors screened abstracts for inclusion criteria and reviewed articles if the abstracts were considered to include information relevant to the aim.

RESULTS

The search terms yielded 30 articles that were sorted based on environment setting, physiological impact, and interventions.

DISCUSSION

The safety of the HCWs and patients can be enhanced through the development and usage of cooler, more comfortable PPE materials and ensembles to help slow the rate of dehydration and support the regulation of core body temperature.

CONCLUSIONS

Heat strain caused by wearing PPE is an occupational health concern for HCWs in the high-risk environment, that is, HCID care. Future studies are needed to develop innovative PPE ensembles that can reduce heat strain and improve well-being.

Investigating the short-term effects of using full-body hospital personal protective equipment and changes in physical workload intensity on human physiological and cognitive performance

The present study investigated the short-term effects of using Personal Protective Equipment (PPE) and physical workload intensity on human physiological and cognitive performance among 21 males and 19 females. PPE1 consisted of a medical coverall and surgical mask, while PPE2 consisted of impermeable full-body coverall, shoe covers, latex gloves, N95 mask, and face shield. Objective assessments were heart rate, energy expenditure, core body temperature, clothing microclimate temperature and humidity, and cognitive performance were the continuous performance test and N-Back test. Subjective assessments included thermal sensation, perceived fatigue/skin wetness/clothing moisture. Using PPE2 and increased workload intensity significantly increased the values of all physiological parameters and the subjective ratings of fatigue, thermal sensation, skin wetness, and clothing moisture. Moreover, the participants' cognitive performance was not affected by the type of PPE.Practitioner summary: Healthcare workers are at the highest risk in the fight against pandemics. Therefore, these people are required to use personal protective equipment. Using this equipment may have difficulties. The results show physiological strain and higher subjective ratings associated with using full-body hospital PPE and increased physical workload.

Occupational heat stress, heat-related effects and the related social and economic loss: a scoping literature review

Introduction

While there is consistent evidence on the effects of heat on workers' health and safety, the evidence on the resulting social and economic impacts is still limited. A scoping literature review was carried out to update the knowledge about social and economic impacts related to workplace heat exposure.

Methods

The literature search was conducted in two bibliographic databases (Web of Science and PubMed), to select publications from 2010 to April 2022.

Results

A total of 89 studies were included in the qualitative synthesis (32 field studies, 8 studies estimating healthcare-related costs, and 49 economic studies). Overall, consistent evidence of the socioeconomic impacts of heat exposure in the workplace emerges. Actual productivity losses at the global level are nearly 10% and are expected to increase up to 30-40% under the worst climate change scenario by the end of the century. Vulnerable regions are mainly low-latitude and low- and middle-income countries with a greater proportion of outdoor workers but include also areas from developed countries such as southern Europe. The most affected sectors are agriculture and construction. There is limited evidence regarding the role of cooling measures and changes in the work/rest schedule in mitigating heat-related productivity loss.

Conclusion

The available evidence highlights the need for strengthening prevention efforts to enhance workers' awareness and resilience toward occupational heat exposure, particularly in low- and middle-income countries but also in some areas of developed countries where an increase in frequency and intensity of heat waves is expected under future climate change scenarios.

Human thermal physiological response of wearing personal protective equipment: An educational building semi-open space experimental investigation

With the outbreak and spread of the COVID-19 epidemic, HCWs are frequently required to wear personal protective equipment (PPE) for nucleic acid sample collection in semi-open transition spaces. Wearing PPE causes significant psychological and physical stress in HCWs. In this study, operative temperature (T_op) and wet-bulb globe temperature (WBGT) were used to assess thermal conditions through field experiments, while multiple physiological parameters were measured in the subjects. The results indicated that the subjects showed statistically significant differences in thermal perception and physiological parameters with and without PPE. Using observed increases in heart rate (HR), auditory canal temperature (T_ac), mean skin temperature (MST), and end-tidal CO₂ pressure, subjects were shown to have an increased metabolic rate and heat storage while wearing PPE. Additionally, a decrease in oxygen concentration was also observed, and this decrease may be linked to fatigue and cognitive impairment. Moreover, HR, MST, and T_ac showed a significant linear relationship, which increased with temperature and operative temperature, and the HR response was stronger with PPE than without PPE. The neutral, preferred, and acceptable temperatures were significantly lower with PPE than without PPE, and the deviations for neutral T_op/WBGT were 9.5/7.1 °C and preferred T_op/WBGT was 2.2/4.0 °C, respectively. Moreover, the upper limits of acceptable WBGT, 29.4 °C with PPE and 20.4 °C without PPE, differed significantly between the two phases. Furthermore, the recorded physiological parameter responses and thermal perception responses of the subjects while wearing PPE indicated that they were at risk of thermal stress. Overall, these results suggest that people who wear PPE should focus on their health and thermal stress. This study provides a reference for the development of strategies to counteract heat stress and improve thermal comfort.

Effect of the cooling clothing integrating with phase change material on the thermal comfort of healthcare workers with personal protective equipment during the COVID-19

Wearing Personal Protective Equipment (PPE) is essential to protect healthcare workers during the COVID-19, but the traditional cooling methods do not meet the requirements of epidemic prevention during the COVID-19. Therefore, the cooling clothing integrated with phase change material (PCM-CC) was proposed for healthcare workers performing nucleic acid sample collection outdoors. Human experiments and subjective questionnaires were used to test the effect of wearing PCM-CC on the thermal sensations of healthcare workers and to analyze the effectiveness of PCM-CC in relieving thermal stress and thereby, improving the thermal comfort of healthcare workers. Results showed that wearing PCM-CC was effective in alleviating various heat symptoms associated with wearing PPE in a hot-temperature environment. Wearing PCM-CC reduced head and facial discomfort by 25% and 41% under the 26 °C thermal environment, while it improved the mean thermal sensation vote (TSV) values by 0.71 and 1.85 under the 26 °C and 32 °C thermal environments, respectively, and made the mean TSV value close to the neutral value. Meanwhile, wearing PCM-CC reduced mean skin temperatures by 0.65 °C, and the pronounced cooling effect was found in the chest. Wearing PCM-CC could be an effective thermoregulation measure to refine the thermal comfort of healthcare workers during the COVID-19 pandemic.

Research on the influence of indoor thermal environment and activity levels on thermal comfort in protective clothing

With the outbreak of infectious diseases such as Corona Virus Disease 2019, medical staff work intensively in isolated plots, medical disposable protective clothing (MDPC) has poor air condition and humidity permeability, which seriously reduces the thermal comfort of medical staff. In this paper, the effect of indoor thermal environment and activity levels on thermal comfort inside MDPC was studied by experiment. Five parts of the body were measured inside MDPC and the appropriate movements were chosen to simulate different levels of labor intensity. Meanwhile, physiological parameters and subjective thermal sensation were statistically analyzed. The results showed the influence range of different indoor temperatures on the temperature and humidity inside MDPC was about 1 °C and 10 %, respectively; it indicated that the environment inside MDPC could be improved by reducing indoor temperature, that is, a cross intelligent adjustment mode was proposed. The effect of labor intensity on the temperature inside MDPC was significantly less than that of humidity. Within 20 min, the humidity changes under moderate and heavy labor intensity were even more than 10 %, and the subjective discomfort threshold of the subjects increased by nearly 50 %. Furthermore, the maximum benefit could be obtained by concentrating cooling on back, forehead, chest and upper arm. Theoretical models of working time, labor intensity, and temperature and humidity inside MDPC under different indoor temperatures and different parts were given. In addition, acceptable regions inside MDPC which were approximately parallelogram in the enthalpy-humidity chart. These conclusions could be a reference for future thermal comfort inside MDPC research.

Field investigation of the heat stress in outdoor of healthcare workers wearing personal protective equipment in South China

Since the advent of coronavirus disease 2019 (COVID-19), healthcare workers (HCWs) wearing personal protective equipment (PPE) has become a common phenomenon. COVID-19 outbreaks overlap with heat waves, and healthcare workers must unfortunately wear PPE during hot weather and experience excessive heat stress. Healthcare workers are at risk of developing heat-related health problems during hot periods in South China. The investigation of thermal response to heat stress among HCWs when they do not wear PPE and when they finish work wearing PPE, and the impact of PPE use on HCWs' physical health were conducted. The field survey were conducted in Guangzhou, including 11 districts. In this survey, HCWs were invited to answer a questionnaire about their heat perception in the thermal environment around them. Most HCWs experienced discomfort in their back, head, face, etc., and nearly 80% of HCWs experienced "profuse sweating." Up to 96.81% of HCWs felt "hot" or "very hot." The air temperature had a significant impact on thermal comfort. Healthcare workers' whole thermal sensation and local thermal sensation were increased significantly by wearing PPE and their thermal sensation vote (TSV) tended towards "very hot." The adaptive ability of the healthcare workers would decreased while wearing PPE. In addition, the accept range of the air temperature (T _a) were determined in this investigation. Graphical Abstract.

The Relationship Between Mindfulness, Fatigue, and Perceived Symptoms Among Frontline Nurses Who Performed Nucleic Acid Sample Collection During the COVID-19 in China: A Cross-Sectional Study

Objective

Given the immense stress faced by medical staff during the COVID-19 pandemic, this study aimed to evaluate the relationship between mindful attention awareness, fatigue, and perceived symptoms among frontline nurses who performed nucleic acid sample collection during the COVID-19 pandemic, to reduce their fatigue and help them cope with perceived uncomfortable symptoms.

Methods

A convenience sampling method was used to survey nurses who travelled to Hainan for nucleic acid sampling in August 2022 using an online (WeChat) questionnaire. A total of 514 frontline nurses who performed nucleic acid tests completed the questionnaire. The questionnaire covered basic demographic information, Mindful Attention Awareness Scale (MAAS) ratings, and Fatigue Severity Scale (FSS) ratings. Spearman correlation analysis was used to separate the relationship between MASS and FSS, and univariate and multivariate factor analyses were used to explore the relevant influences contributing to the occurrence of fatigue.

Results

A total of 514 individuals completed the survey,93.97% (n=483) were female, mean age was 31.15 ± 5.7, MASS score was 69.01 ± 13.53, and 296 (57.59%) nurses experienced symptoms of fatigue during the auxiliary period. Spearman correlation analysis showed that FSS was associated with MASS. Multifactorial analysis showed that sex, age, marital status, fertility status, years of work, adaptation to dietary habits, hidrorrhea, and MAAS scores affected the presence of fatigue symptoms among the medical staff in Hainan (P<0.05).

Conclusion

The psychological status of frontline nurses undergoing nucleic acid testing during the pandemic was poor, and the appearance of fatigue symptoms could be effectively reduced by increasing levels of positive thinking among medical staff to help them cope with public health emergencies.

Thermophysiological and Perceptual Responses of Amateur Healthcare Workers: Impacts of Ambient Condition, Inner-Garment Insulation and Personal Cooling Strategy

While personal protective equipment (PPE) protects healthcare workers from viruses, it also increases the risk of heat stress. In this study, the effects of environmental heat stress, the insulation of the PPE inner-garment layer, and the personal cooling strategy on the physiological and perceptual responses of PPE-clad young college students were evaluated. Three levels of wet bulb globe temperatures (WBGT = 15 °C, 28 °C, and 32 °C) and two types of inner garments (0.37 clo and 0.75 clo) were chosen for this study. In an uncompensable heat stress environment (WBGT = 32 °C), the effects of two commercially available personal cooling systems, including a ventilation cooling system (VCS) and an ice pack cooling system (ICS) on the heat strain mitigation of PPE-clad participants were also assessed. At WBGT = 15 °C with 0.75 clo inner garments, mean skin temperatures were stabilized at 31.2 °C, H_skin was 60-65%, and HR was about 75.5 bpm, indicating that the working scenario was on the cooler side. At WBGT = 28 °C, T_skin plateaued at approximately 34.7 °C, and the participants reported "hot" thermal sensations. The insulation reduction in inner garments from 0.75 clo to 0.37 clo did not significantly improve the physiological thermal comfort of the participants. At WBGT = 32 °C, T_skin was maintained at 35.2-35.7 °C, H_skin was nearly 90% RH, T_core exceeded 37.1 °C, and the mean HR was 91.9 bpm. These conditions indicated that such a working scenario was uncompensable, and personal cooling to mitigate heat stress was required. Relative to that in NCS (no cooling), the mean skin temperatures in ICS and VCS were reduced by 0.61 °C and 0.22 °C, respectively, and the heart rates were decreased by 10.7 and 8.5 bpm, respectively. Perceptual responses in ICS and VCS improved significantly throughout the entire field trials, with VCS outperforming ICS in the individual cooling effect.

Personal protective equipment for COVID-19 among healthcare workers in an emergency department: An exploratory survey of workload, thermal discomfort and symptoms of heat strain

OBJECTIVES

To examine workload, thermal discomfort and heat-related symptoms among healthcare workers (HCWs) in an Australian ED during the COVID-19 pandemic.

METHODS

A cross-sectional study design was employed among HCWs in an ED at a metropolitan hospital in Brisbane, Australia. Respondents provided demographic information including their self-reported age, sex, height, weight, role (e.g. doctor, nurse), and whether they wore personal protective equipment (PPE) during their shift, rated as either Full PPE, Partial PPE, or usual uniform or scrubs. The workload of HCWs was assessed with the National Aeronautics and Space Administration's task load index (NASA-TLX). Thermal discomfort was evaluated using scales from the International Organisation for Standardisation. Responders rated their subjective heat illness using the Environmental Symptoms Questionnaire.

RESULTS

Fifty-nine HCWs completed the survey (27 male, 31 female, one prefer not to answer). Overall workload from the NASA-TLX was 64.6 (interquartile range [IQR] 56.5-73.3) for doctors, 72.5 (IQR 63.3-83.3) for nurses and 66.7 (IQR 58.3-74.17) for other staff, representing moderate to high ratings. Eighty-one percent reported thermal sensation to be slightly warm, warm, or hot, and 88% reported being uncomfortable, ranging from slightly to extremely. Ninety-seven percent reported at least one heat-strain symptom. More than 50% reported light-headedness or headache and approximately 30% reported feeling dizzy, faint, or weak.

CONCLUSIONS

ED HCWs experience thermal discomfort when wearing PPE. Combined with their workloads, HCWs experienced symptoms related to heat strain. Therefore, careful consideration should be given to managing heat strain among HCWs when wearing PPE in an ED.

Determination of thermal comfort among nurses working with personal protective equipment in COVID-19 clinics

AIMS

This study aimed to determine thermal comfort among nurses working with personal protective equipment in COVID-19 clinic.

METHODS

In this study, a descriptive design was carried out between June and September 2020. Sample of the study consisted of 246 nurses (77.6%) who worked in the COVID-19 clinics with personal protective equipment. We used a questionnaire to determine thermal comfort of nurses; a follow-up form to determine the factors affecting thermal comfort; and the ASHRAE Thermal Sensation Scale. Four measurements and follow-ups were made three times.

RESULTS

More than half of nurses complained of ambient temperature and ventilation, one-third complained of humidity and nearly half complained of poor air quality. The mean thermal comfort score of nurses working in COVID-19 clinics was 1.19 (SD = 0.75). The thermal comfort of the nurses was negatively affected in all measurements except before wearing personal protective equipment. The highest scores were measured leaving the patient room and before removing personal protective equipment (M = 2.65, SD = 0.58).

CONCLUSION

The thermal comfort, work performance and stress levels of the nurses were negatively affected by working with personal protective equipment. This study reveals the necessity of improving the working conditions of nurses, including working hours, environment and personal protective equipment.

Physical problems of prolonged use of personal protective equipment during the COVID-19 pandemic: A scoping review

BACKGROUND

It is widely believed that using personal protective equipment (PPE) provides high levels of protection for healthcare workers (HCWs) in the fight against coronavirus disease (COVID-19). However, the long-term use of PPE is inconvenient for HCWs and may cause physical discomfort. These factors could result in poor compliance and disrupt the health and safety of HCWs, which may negatively affect the patient's safety.

OBJECTIVE

This study aimed to investigate the literature for the purpose of collecting convincing evidence of HCWs' physical problems associated with PPE use during the COVID-19 pandemic.

METHODS

This scoping review was conducted using PubMed, Embase, ProQuest, Science Direct, Springer, Biomed Central, and Google Scholar to identify the related literature.

RESULTS

HCWs have experienced various physical disorders including skin, respiratory, musculoskeletal, nervous, urinary, and circulatory system problems that are associated with PPE in various body systems. Among these, skin problems were the most frequent physical problems.

CONCLUSIONS

The literature demonstrated the adverse impacts of using PPE on HCWs. Therefore, healthcare policymakers should take the appropriate measures to improve the work environment during the COVID-19 pandemic, which could consequently prevent and mitigate the adverse effects of using PPE.

Global Healthcare Needs Related to COVID-19: An Evidence Map of the First Year of the Pandemic

The COVID-19 pandemic has exposed gaps and areas of need in health systems worldwide. This work aims to map the evidence on COVID-19-related healthcare needs of adult patients, their family members, and the professionals involved in their care during the first year of the pandemic. We searched the databases MEDLINE, Embase, and Web of Science. Two reviewers independently screened titles and abstracts and assessed full texts for eligibility. Disagreements were resolved by consensus. Descriptive data were extracted and inductive qualitative content analysis was used to generate codes and derive overarching themes. Thirty-six studies met inclusion criteria, with the majority reporting needs from the perspective of professionals (35/36). Professionals' needs were grouped into three main clusters (basic, occupational, and psycho-socio-emotional needs); patients' needs into four (basic, healthcare, psycho-socio-emotional, and other support needs); and family members' needs into two (psycho-socio-emotional and communication needs). Transversal needs across subgroups were also identified and grouped into three main clusters (public safety, information and communication, and coordination and support needs). This evidence map provides valuable insight on COVID-19-related healthcare needs. More research is needed to assess first-person perspectives of patients and their families, examine whether needs differ by country or region, and evaluate how needs have evolved over time.

Psychological Responses of Health Care Workers Are Strongly Associated With Pandemic Management

Background

Globally, governments adopted protective measures to stabilize the worsening COVID-19 pandemic situation. These measures had a large impact on health care workers (HCWs) and could make the work environment more stressful for them. Therefore, we explored the associations of the psychological responses of HCWs and pandemic management among Slovak health care workers during the second wave of the pandemic.

Materials and Methods

We obtained data about psychological responses, COVID-19 experiences, information overload, non-adherence of the public, work stress and barriers and facilitators of health care provision from HCWs at the COVID-19-related departments of one hospital that mainly covered eastern Slovakia (215 health care professionals, 77.7% females, M/SD = 44.4). Data were analyzed using logistic regression models adjusted for gender.

Results

Pandemic management was most strongly associated with psychological responses, such as irritability, sadness, anxiety, dizziness, and back pain, in health care workers. The non-adherence of the public had the strongest associated psychological impact on HCWs, mostly affecting anxiety and irritability (odds ratios, ORs varying from 3.9 to 7.0). From the barriers and facilitators of health care provision, the use of personal protective equipment had the most impact psychologically, whereas efficient department management was most protective, with ORs around 0.3.

Conclusion

Pandemic management has a large impact on health care workers, and promoting resilience may seriously decrease job-related stress and associated psychological responses of HCWs.

The Evaluation of Physiological Index Changes and Safety Work of Female Medical Staff With Different Medical Protection Standards in the Ward of COVID-19

Background

Effective personal protective equipment (PPE) contribute to the prevention of COVID-19 infection. However, it is necessary to evaluate the potential risk of different medical protections in the isolation ward of COVID-19.

Objectives

We aimed to explore the dynamics in physiological indexes of medical staff under primary and secondary PPE in the isolation ward of COVID-19 and provide the scientific basis for determining the safe work strategy.

Materials and Methods

In this study, 30 female nurses were selected to simulate medical work under the primary or secondary PPE, respectively. The oral temperature, axillary temperature, heart rate, respiratory rate, blood oxygen saturation, and blood pressure were measured and recorded every 20 min. The subjective adverse symptoms were recorded every 30 min. The blood glucose and weight of the individuals were measured and recorded before and after the trial.

Results

The results indicated that the median trial persistence time in the participants with moderate-intensity work wearing the secondary PPE (70.0 min) was much lower than that with moderate-intensity work wearing the primary PPE (180 min) and with light-intensity work wearing the primary PPE (110 min; p < 0.05). Importantly, the heart rate, oral/axillary temperature, and respiratory rate of physiological indexes of the participants under moderate-intensity work wearing the secondary PPE increased significantly faster than the primary PPE (p < 0.001), while blood oxygen saturation decreased significantly faster than the primary PPE (p < 0.001). In addition, the proportions of subjective adverse symptoms (such as dry mouth, dizziness, palpitations, and anhelation) were much higher than primary PPE (p < 0.001). The average sweat volume and blood glucose consumption of participants under moderate-intensity work wearing primary PPE were higher than secondary PPE (p < 0.001).

Conclusion

The combination of an exacerbated workload and secondary PPE worn by COVID-19 healthcare workers increases the change in physiological indicators, and in some cases the adverse symptoms, which can affect and even suspend their medical work. For any medical institution, there is room for improvement in terms of bioethics of a "Job Well Done" to reduce the risks of medical activities under secondary PPE.

Thermal discomfort caused by personal protective equipment in healthcare workers during the delta COVID-19 pandemic in Guangzhou, China: A case study

Background

In contrast to the previous COVID-19 pandemic, most frontline healthcare workers (HCWs) worked on residents’ nucleic acid tests in outdoor environments, instead of taking care of COVID-19 patients in hospitals during the hot summer of 2021. Therefore, it is necessary to investigate the prevalence and characteristics of thermal discomfort caused by personal protective equipment (PPE).

Methods

A cross-sectional survey was conducted online at hospitals from 11 administrative regions of Guangzhou for the assessment of thermal discomfort among HCWs from June 12–16, 2021. Univariate and logistic regression analyses were used to explore the risk factors associated with thermal discomfort.

Results

A total of 3658 valid responses were collected. The thermal discomfort and humid discomfort levels increased from 2.91 ± 1.19 to 3.61 ± 0.72 and from 0.98 ± 1.36 to 3.06 ± 1.1 after wearing PPE, respectively (p < 0.01). Feelings of being “very hot” and “uncomfortably humid” were the most influenced by wearing PPE, increasing from 31% to 69.1% and from 9.1% to 45.7%, respectively. There were significant increases in the thermal discomfort level (3.75 ± 0.57 vs. 3.33 ± 0.89, p < 0.01) and the humid discomfort level (3.33 ± 0.95 vs. 2.54 ± 1.19, p < 0.01) between the comfortable group and uncomfortable group, accompanied by similar patterns in the feelings of being “very hot” and “uncomfortably humid.” For general thermal-related symptoms, the most common new-onset symptom was profuse sweating (80%) followed by labored breathing (55.2%) and excessive dehydration (46.8%), while facial swelling (74%) was associated with local thermal-related symptoms, followed by hand maceration erosion (56.7%) and visual impairment (49.3%). In the multivariate analysis, the apparent temperature of the environment (≥35 °C), working in negative-pressure ambulances and outdoors, continuing to wear PPE for 1–3 days during this period, being aged >40 years, and previous experiences fighting the pandemic were independently associated with thermal discomfort (p < 0.01). Immediately after PPE removal, 32.3% of respondents considered drinking ice water/another drink, followed by 25% shortening the duration of wearing PPE and 19.1% going to the toilet. A large proportion of the participants looked forward to modifications to the material of the suit (72.9%) and mask (53.4%) for heat dissipation and dehumidification, as well as anti-fogging goggles (60.2%), adding hydration equipment to PPE (53.4%), and using soft materials to reduce pressure (40%).

Conclusions

Thermal discomfort is common and degrades health physiology related to PPE in summer environments. This suggests that modifications to the current working practices are urgently required to improve the resilience of HCWs and enhance their services during pandemics.

Heat Strain and Use of Heat Mitigation Strategies among COVID-19 Healthcare Workers Wearing Personal Protective Equipment-A Retrospective Study

The combination of an exacerbated workload and impermeable nature of the personal protective equipment (PPE) worn by COVID-19 healthcare workers increases heat strain. We aimed to compare the prevalence of heat strain symptoms before (routine care without PPE) versus during the COVID-19 pandemic (COVID-19 care with PPE), identify risk factors associated with experiencing heat strain, and evaluate the access to and use of heat mitigation strategies. Dutch healthcare workers (n = 791) working at COVID-19 wards for ≥1 week, completed an online questionnaire to assess personal characteristics, heat strain symptoms before and during the COVID-19 pandemic, and the access to and use of heat mitigation strategies. Healthcare workers experienced ~25× more often heat strain symptoms during medical duties with PPE (93% of healthcare workers) compared to without PPE (30% of healthcare workers; OR = 25.57 (95% CI = 18.17-35.98)). Female healthcare workers and those with an age <40 years were most affected by heat strain, whereas exposure time and sports activity level were not significantly associated with heat strain prevalence. Cold drinks and ice slurry ingestion were the most frequently used heat mitigation strategies and were available in 63.5% and 30.1% of participants, respectively. Our findings indicate that heat strain is a major challenge for COVID-19 healthcare workers, and heat mitigations strategies are often used to counteract heat strain.

Risk of Dehydration Due to Sweating While Wearing Personal 2 Protective Equipment in COVID-19 Clinical Care: A Pilot Study

Objective: The objectives of this study were (a) to determine the physical impact of the personal protective equipment (PPE) used in COVID-19 care, specifically the impact on the hydration state of the temperature and the comfort of the healthcare workers who use it, and (b) to show the high-fidelity simulated environment as an appropriate place to test the experimental designs to be developed in real environments for COVID-19. Background: All healthcare staff use full PPE in the care of COVID-19 patients. There are problems, such as excessive sweating, which have not been quantified thus far. Methods: A descriptive pilot design was used in a simulated high-fidelity setting. There was paired activity, with mild–moderate physical activity, between 45 and 60 min continuously, with the COVID-19 PPE. Sixteen intensive care nurses were selected. The before–after differential of weight, thirst, weight use of the PPE, body temperature, thermal body image, general and facial warmth sensation, and perspiration sensation were measured. Results: All subjects lost weight in the form of sweat with both PPEs during the simulation scenario, with a mean of 200 g (0.28% of initial weight), and increased thirst sensation. Body thermal image increased by 0.54 °C in people using the full COVID-19 PPE. Conclusions: The use of PPE in the management of critically ill COVID-19 patients generates weight loss related to excessive sweating. The weight loss shown in this pilot test is far from the clinical limits of dehydration. The use of ventilated PPE, such as PAPR, reduce the body temperature and heat sensation experienced by the users of it; at the same time, it improves the comfort of those who wear it. The simulated environment is a suitable place to develop the piloting of applicable research methodologies in future studies in a real environment.

A pilot study of core body temperatures in healthcare workers wearing personal protective equipment in a high-level isolation unit

Personal protective equipment used by healthcare workers to mitigate disease transmission risks while caring for patients with high-consequence infectious diseases can impair normal body cooling mechanisms and exacerbate physiological strain. Symptoms of heat strain (e.g., cognitive impairment, confusion, muscle cramping) are especially harmful in the high-risk environment of high-consequence infectious disease care. In this pilot study, the core body temperatures of healthcare workers were assessed using an ingestible, wireless-transmission thermometer while performing patient care tasks common to a high-level isolation unit setting in powered air purifying respirator (PAPR)-level. The objective was to determine the potential for occupational health hazard due to heat stress in an environmentally controlled unit. Maximum core temperatures of the six participants ranged from 37.4 °C (99.3 °F) to 39.9 °C (103.8°F) during the 4-hr shift; core temperatures of half (n = 3) of the participants exceeded 38.5 °C (101.3 °F), the upper core temperature limit. Future investigations are needed to identify other heat stress risks both in and outside of controlled units. The ongoing COVID-19 pandemic offers unique opportunities for field-based research on risks of heat stress related to personal protective equipment in healthcare workers that can lead to both short- and long-term innovations in this field.

One Year on: An Overview of Singapore's Response to COVID-19-What We Did, How We Fared, How We Can Move Forward

Background-One year has passed since the first COVID-19 case in Singapore. This scoping review commemorates Singaporean researchers that have expanded the knowledge on this novel virus. We aim to provide an overview of healthcare-related articles published in peer-reviewed journals, authored by the Singapore research community about COVID-19 during the first year of the pandemic. Methods-This was reported using the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) protocol. It included healthcare-related articles about COVID-19 published between 23 January 2020 and 22 January 2021 with a Singapore-affiliated author. MEDLINE, Embase, Scopus, Web of Science, CINAHL, PsycINFO, Google Scholar, and local journals were searched. The articles were screened independently by two reviewers. Results-The review included 504 articles. Most of the articles narrated the changes to hospital practice (210), while articles on COVID-19 pathology (94) formed most of the non-narrative papers. Publications on public health (61) and the indirect impacts to clinical outcomes (45) were other major themes explored by the research community. The remaining articles detailed the psychological impact of the pandemic (35), adaptations of medical education (30), and narratives of events (14). Conclusion-Amidst a resurgence of community cases involving variant COVID-19 strains, the resources from the research community will provide valuable guidance to navigate these uncertain times.

Hot days and Covid-19: Online survey of nurses and nursing assistants to assess occupational heat stress in Germany during summer 2020

OBJECTIVES

Our aim was to identify if working during hot days while wearing Covid-19 related personal protective equipment causes occupational heat stress for nurses and nursing assistants in Germany.

DESIGN

Using an online survey, we assessed the impact of hot weather on nurses and nursing assistants working with personal protective equipment. Respondents were recruited by distributing the link to the survey via personal communication, email and various social media channels to nursing staff from hospitals, nursing homes and outpatient care.

RESULTS

There were in total 428 participants (18.2% male, 82.5% female), mostly (30.5%) aged between 45 and 55 years. Half of respondents (48.3%) had more than 20 years of experience in nursing. Cardiac, pulmonary, or other pre-existing conditions were reported by 46.2%.Nurses and nursing assistants working in personal protective equipment during hot days were exposed to occupational heat stress. Work was found exhaustive by 96.5% of the participants during those days. 93.0% reported breathing problems and 85.8% reported difficulties with focusing on their work. Many workplaces did not provide adequate heat protection, with distinct differences concerning the amount of prophylactic and heat mitigating measures across institutions. There were significant differences across institutions when it comes to the number of drinks served (p < 0.001), the availability of room thermometers (p < 0.001), the use of mobile cooling devices (p < 0.001) and fans (p < 0.05).

CONCLUSIONS

Results suggest employers must make more of an effort to provide adequate heat protection for their nursing staff. In order to ensure patient care, there is a need for action; in particular, attention must be paid to the pre-existing health conditions of the nursing staff.

COVID-19 and heat waves: New challenges for healthcare systems

Heat waves and Covid-19 overlap, as this pandemic continues into summer 2021. Using a narrative review, we identified overlapping risk groups and propose coping strategies. The high-risk groups for heat-related health problems as well as for high-risk COVID-19 groups overlap considerably (elderly with pre-existing health conditions). Health care facilities will again be challenged by Covid-19 during heat waves. Health care personnel are also at risk of developing heat related health problems during hot periods due to the use of personal protective equipment to shield themselves from SARS-CoV-2 and must therefore be protected from excessive heat periods. Some existing recommendations for heat health protection contradict recommendations for COVID-19 protection. This paper provides a preliminary overview of possible strategies and interventions to tackle these ambiguities. The existing recommendations for protection against heat-related illnesses need revisions to determine whether they include essential aspects of infection control and occupational safety and how they may be supplemented.

A Web Survey to Evaluate the Thermal Stress Associated with Personal Protective Equipment among Healthcare Workers during the COVID-19 Pandemic in Italy

The pandemic has been afflicting the planet for over a year and from the occupational point of view, healthcare workers have recorded a substantial increase in working hours. The use of personal protective equipment (PPE), necessary to keep safe from COVID-19 increases the chances of overheating, especially during the summer seasons which, due to climate change, are becoming increasingly warm and prolonged. A web survey was carried out in Italy within the WORKLIMATE project during the summer and early autumn 2020. Analysis of variance (ANOVA) was used to evaluate differences between groups. 191 questionnaires were collected (hospital doctor 38.2%, nurses 33.5%, other healthcare professionals 28.3%). The impact of PPE on the thermal stress perception declared by the interviewees was very high on the body areas directly covered by these devices (78% of workers). Workers who used masks for more than 4 h per day perceived PPE as more uncomfortable (p < 0.001) compared to the others and reported a greater productivity loss (p < 0.001). Furthermore, the study highlighted a high perception of thermal stress among healthcare workers that worn COVID-19-PPE and this enhances the need for appropriate heat health warning systems and response measures addressed to the occupational sector.

Heat strain in chemical protective clothing in hot-humid environment: Effects of clothing thermal properties

Heat strain experienced by individuals wearing chemical protective clothing (CPC) is severe and dangerous especially in hot-humid environment. The development of material science and interdisciplinary studies including ergonomics, physiology and heat transfer is urgently required for the reduction of heat strain. The aim of this paper was to study the relationship among clothing thermal properties, physiological responses and environmental conditions. Three kinds of CPC were selected. Eight participants wore CPC and walked (4 km/h, two slopes with 5% and 10%) on a treadmill in an environment with (35±0.5) °C and RH of (60±5)%. Core temperature, mean skin temperature, heart rate, heat storage and tolerance time were recorded and analyzed. Physiological responses were significantly affected by the clothing thermal properties and activity intensity in hot-humid environment. The obtained results can help further development of heat strain model. New materials with lower evaporative resistance and less weight are necessary to release the heat strain in hot-humid environments.