Administrative controls

Administrative controls are modifications in work procedures including timing of work, policies, rules and regulations, work practices (including training, supervision, housekeeping, personal hygiene practices, equipment maintenance, and schedules) that are instituted to prevent or eliminate exposure of staff, patients, and visitors to any hazards that may be present within the healthcare settings. ^{Reference de Perio, Dowell and Delaney32,Reference Su, de Perio, Cummings, McCague, Luckhaupt and Sweeney35,Reference Wong, Goh and Tan36} Administrative controls are very effective in reducing or limiting the transmission of infectious diseases in healthcare settings through the identification of all the potential exposure pathways and the implementation of practices and policies required to prevent or eliminate the source of spread of exposures. The primary objective of administrative control measures implemented in hospitals is to ensure that patients, visitors, and healthcare staff who may be infected with any infectious disease such as COVID-19 could be promptly identified, diagnosed, isolated, and treated in an effort to prevent the spread of the infection to others within the hospital. ^{Reference de Perio, Dowell and Delaney32,Reference Chang, Lin and Tsai37,Reference Sydnor and Perl38} Several studies have reported that the success of any administrative control measures instituted within healthcare settings is heavily dependent on the careful guidance and directions provided by the occupational health and safety departments and any infection prevention disease committees that may have been established to manage and prevent the spread of the infection. ^{Reference de Perio, Dowell and Delaney32,Reference Su, de Perio, Cummings, McCague, Luckhaupt and Sweeney35,48} The occupational health and safety departments within healthcare facilities serve to ensure that the organization has the resource capacity, knowledge, training, policies and procedures to adequately implement any established infection control measures. According to Su et al., ^{Reference Su, de Perio, Cummings, McCague, Luckhaupt and Sweeney35} administrative control measures can be effective in reducing the transmission of infections if they are well implemented, adequately enforced, and continually monitored to better facilitate staff, patient, and visitor compliance. Several studies have reported that administrative control measures such as triage procedures at main entrances of the facility, limiting the number of patients and visitors to the facility, cohorting of patients and healthcare workers, and physical distancing practices are all effective measures of preventing or limiting the spread of SARS-CoV-2 infection in hospitals. ^{Reference de Perio, Dowell and Delaney32,Reference Su, de Perio, Cummings, McCague, Luckhaupt and Sweeney35–Reference Lu, Wang, Yu, Yang and Zhao40,Reference Cho, Kang and Park43–Reference Palmore and Henderson47,Reference Al-Shamsi, Alhazzani and Alhuraiji49–Reference Said, Perl and Sears59,Reference Zhang, Sun, Latour, Hu and Qian61} According to Lu et al., ^{Reference Lu, Wang, Yu, Yang and Zhao40} the establishment of infection control strategies such as material preparation and distribution, training on infection prevention measures, a triage strategy, limiting traffic into the hospital, reorganization of hospital departments to minimize the number of people present at any particular time, and keeping the environment sanitized are very effective strategies to contain the spread of the SARS-CoV-2.

Triaging procedures

Triaging is a systematic process used to control patient flow in a clinic or a facility to ensure that those with urgent healthcare needs are prioritized to receive immediate care. ^{Reference FitzGerald, Jelinek, Scott and Gerdtz62} Studies have reported that the implementation of triaging processes within the healthcare system has significant potential to prevent the spread of nosocomial infection through prompt identification of patients, staff, and visitors who may be infected with SARS-CoV-2. Furthermore, ensuring the triaging procedures are tailored towards prompt identification and detection of SARS-CoV-2 affected individuals is very critical in reducing exposure by staff, patients, and visitors. ^{Reference Wong, Goh and Tan36,Reference Wang, Wang and Lin39,Reference Chung, Lee and Kim63–Reference Wake, Morgan, Choi and Winn67} Lee et al., ^{Reference Lee, Wang, Lin, Kung, Lan and Lee68} reported that the implementation of proper triage procedures is an important factor in helping to prevent the spread of SARS-CoV-2. According to Wong et al., ^{Reference Wong, Goh and Tan36} Wang et al., ^{Reference Wang, Wang and Lin39} and Lee et al., ^{Reference Lee, Wang, Lin, Kung, Lan and Lee68} an effective triaging process can be established for early identification of patients, staff, and visitors who may be infected with SARS-CoV-2, and should be set up only at the main entrances of the healthcare facility to ensure that all patients, staff, and visitors entering the facility are screened using the same standard questionnaire. However, in order to minimize congestion at the facilities’ entrances, it is suggested that different triage stations should be established at 2 different main entrances; 1 to be used by staff and the other by patients and visitors. Furthermore, it is important that all other access to the healthcare facility is inaccessible to all staff, patients, and visitors. Lee et al., ^{Reference Lee, Wang, Lin, Kung, Lan and Lee68} reported that performing temperature checks, asking about patients travel history, close contacts, and new symptoms, are very important information to gather as part of the triage process. They reported the installation of infrared thermal cameras within hospitals in Taiwan as part of the triaging process for prompt detection of patients, visitors, or staff with elevated body temperatures (fever) as an effective approach for temperature checks in hospitals. Numerous studies have reported that the most common screening criteria questions used in most healthcare facilities at triaging stations include the following: asking patients/ staff/ visitors if (i) they are experiencing any symptoms of upper respiratory infection, (ii) travelled outside the country within the past 14 days, (iii) if they have visited any facility with known outbreak, and (iv) if they have been in contact with any individual who has been diagnosed with COVID-19. ^{Reference Wong, Goh and Tan36,Reference Wang, Wang and Lin39,Reference Ornaghi, Callegari and Milazzo69–Reference Quah, Tan and Fua72} If a patient, staff or visitor responds yes to any of the questions, it is recommended that they be immediately placed in an airborne isolation room and tested for SARS-CoV-2. According to Wang et al., ^{Reference Wang, Wang and Lin39} the implementation of the triage procedures in various hospitals have been very effective in prompt identification of patients, staff, and visitors with infection and thus has significantly reduced the risk of transmissions in several hospitals.

Limiting traffic in healthcare facilities

Studies have reported that limiting the number of people present in the healthcare facility at any given time is an effective strategy for the prevention and minimization of potential exposure and spread of SARS-CoV-2 in the facility. ^{Reference de Perio, Dowell and Delaney32,Reference Lu, Wang, Yu, Yang and Zhao40,Reference Lai, Tang, Chau, Fung and Li41,Reference Falvey, Krafft and Kornetti73–Reference Singh, Green, Lindblom, Reif, Thakkar and Papali76} Consequently, a number of hospitals worldwide cancelled, postponed, or severely reduced several healthcare services including elective surgeries, patient follow-up, face-to-face patient consults, cancer screening/prevention services, and certain diagnostic and treatment services. Furthermore, several hospitals shifted to telemedicine, restricted in-hospital visitations, and implemented strategies for some staff to work from home in an effort to minimize potential pathways of exposure to SARS-CoV-2. ^{Reference de Perio, Dowell and Delaney32,Reference Wong, Goh and Tan36,Reference Lai, Tang, Chau, Fung and Li41,Reference Osei, Francis, Mohamed, Sheraz and Soltani-Mayvan77} Although these measures may potentially reduce the spread of SARS-COV-2, it is recommended that 1 should carefully weigh the benefits of patient care with both the risk of patients contracting SARS-COV-2, and the downstream consequences of delaying, modifying, or cancelling diagnostic and treatment activities. ^{Reference Osei, Francis, Mohamed, Sheraz and Soltani-Mayvan77} A study conducted by The Lancet Digital Health reported that the use of telemedicine increased from 10% to 75% in the UK during the height of the COVID-19 lockdown. ^{Reference McCall78} According to Lai et al., ^{Reference Lai, Tang, Chau, Fung and Li41} the postponement of elective surgeries will also ensure that healthcare facilities have adequate resources (beds, ventilators etc.) and staff for possible surge in COVID-19 cases. Liu et al., ^{Reference Liu, Kang and Wang42} also reported that adding restrictions to the number of visitors, maintaining a visitor log, and limiting the number of entrances to the hospital are important access control strategies to limit the number of people in the hospital, thereby reducing nosocomial spread of SARS-CoV-2.

Lu et al., ^{Reference Lu, Wang, Yu, Yang and Zhao40} described infection control measures that were established in a West China Hospital in an Ear-Nose-and-Throat (ENT) department to protect healthcare workers and patients from potential SARS-CoV-2 infection. They reported that in order to decrease the number of patients present at the ENT clinic, they separated the waiting area from the treatment area, reduced the number of appointments, re-scheduled appointments at different times, restricted visitation to a single visitor, increased online consulting services, and initially suspended elective surgeries. They concluded that the infection control measures that were implemented significantly reduced the number of people in the clinic and were very effective in preventing nosocomial SARS-CoV-2 infection in the ENT department. Wang et al., ^{Reference Said, Perl and Sears59} investigated the impact of implementing recommendations that were outlined by the National Cancer Center and Chinese Academy of Sciences for the protection of patients and staff from contracting SARS-CoV-2. They reported suspending elective surgeries, reducing inpatient and outpatient visits in the oncology department, suspending chemotherapy treatments where possible, and using oral administration of anti-cancer drugs for patients. They observed that the precautions employed were very successful in preventing the spread of cross infection since no COVID-19 cases were reported among staff or patients in the department during the time of the study. They concluded that during the COVID-19 era, it is possible to continue to provide treatment to patients with cancer who urgently require it, without compromising patients’ health, by implementing appropriate safety measures that can prevent cross infection. Al-Shamsi et al., ⁴⁸ investigated some practical approaches to manage cancer treatment during the SARS-CoV-2 pandemic. They recommended that deferring elective surgeries and outpatient visits, postponing chemotherapy and radiation treatment on a case-by-case basis, using alternative treatments such as oral anti-cancer therapy where possible, and utilizing telemedicine for patient follow-up and support, are imperative measures that can help reduce the number of people in the facility and help curb the spread of infection and prevent potential risk of exposure to SARS-CoV-2. They concluded that these measures have the potential to minimize the spread of COVID-19 in healthcare facilities and protect patients who are immunocompromised from contracting the infection. Jindal et al., ^{Reference Jindal, Sahu, Gaikazian, Siddiqui and Jaiyesimi53} also investigated the management practices of cancer patients during this pandemic and suggested similar approaches in order to provide safe cancer care. They suggested the deferment of cancer patients’ regimes if they are tested positive for COVID-19/SARS-CoV-2 and acknowledged that treatment centers pose a great risk of exposure to the infection. They concluded that although deferring treatment could minimize the spread of SARS-CoV-2, it can potentially compromise the health of patients and their condition could progress from potentially curable (with near-normal life expectancy) to likely incurable (with much reduced life expectancy).

Cohorting of patients

The World Health Organization characterized cohorting patients as the concept of separating patients who have been infected by the same laboratory confirmed pathogen into 1 ward. ³³ There is sufficient evidence that suggests that cohorting patients is an effective measure in containing and preventing the spread of infections such as gastroenteritis in hospital settings, ^{Reference Barclay, Park and Vega50,Reference MacCannell, Umscheid and Agarwal55,Reference Rajagopalan and Yoshikawa79,Reference Lopman, Andrews, Sarangi, Vipond, Brown and Reacher80} and has been reported to be potentially effective to reduce the risk of transmission and exposure to SARS-CoV-2. ^{Reference Cho, Kang and Park43,Reference Patterson, Marks and Martinez-Garcia44,Reference Montoya, Jenq and Mills56} The World Health Organization and the US Centre for Disease Control and Prevention guidelines recommended the cohorting of COVID-19 patients as it can potentially limit the number of patients and healthcare workers who could be exposed to the virus and will help contain its spread in the healthcare settings. Cohorting of patients has been a common practice in infection control strategies that are utilized to manage outbreaks and the prevention of the spread of nosocomial infection. ^{Reference Cho, Kang and Park43,Reference Patterson, Marks and Martinez-Garcia44,Reference Montoya, Jenq and Mills56,Reference Lee, Wang, Lin, Kung, Lan and Lee68}

According to Lee et al., ^{Reference Lee, Wang, Lin, Kung, Lan and Lee68} cohorting patients is an effective strategy to reduce nosocomial SARS-CoV-2 infection when coupled with other measures such as triaging procedures and the use of personal protective equipment. Patterson et al., ^{Reference Patterson, Marks and Martinez-Garcia44} investigated measures needed to protect patients with comorbidities who have been admitted to the hospital to prevent them from being exposed to SARS-CoV-2. They reported using clinical, laboratory, and radiological markers to promptly identify and cohort patients with COVID-19 in order to minimize the risk of exposure to staff and other patients. The implementation of the cohorting strategy ensured that patients who tested negative for COVID-19/SARS-CoV-2 did not acquire the infection during their hospital visit, as they were housed in single occupancy rooms distanced from patients who were COVID-19 positive. Furthermore, they reported that cohorting patients helped alleviate the demand for single occupancy rooms, as patients who are infected were grouped together in the same space. As a result, single rooms were then utilized for patients with comorbidities or at greater risk for complications due to COVID-19. They concluded that cohorting patients, is an effective measure in preventing healthcare-associated COVID-19 infection among patients with comorbidities.

Congregate care settings such as long-term care homes or nursing homes are also highly susceptible to COVID-19 outbreaks. Cohorting residents, can often be a mitigation strategy that is utilized in congregate care settings as an outbreak management strategy. Montoya et al., ^{Reference Montoya, Jenq and Mills56} examined some of the interventions implemented to manage COVID-19 outbreaks at 3 different nursing homes in Michigan to avert further transmission to other residents and staff. They reported using cohorting residents with COVID-19 as 1 of the many reduction and control strategies implemented to manage the outbreaks at each of the nursing homes. They found that cohorting residents who were SARS-CoV-2 positive through prompt testing decreased asymptomatic transmission to other staff and residents. They concluded that cohorting the residents is an effective method for outbreak management and lowering the prevalence of COVID-19 in nursing home settings.

Cohorting of healthcare workers

Cohorting of healthcare workers is also considered an effective administrative control measure that can be employed to minimize the exposure and reduce the risk of transmission of SARS-CoV-2 since the approach could significantly limit the number of staffs who interact with potentially infected patients. ^{Reference de Perio, Dowell and Delaney32,34,Reference Chandy, Nasir, Srinivasan, Klass, Nicolaou and B Babu45,Reference Abad, Barker and Safdar46,Reference French, McKenzie and Coope52,Reference Bonten, Austin and Lipsitch58,Reference Zhang, Sun, Latour, Hu and Qian61} In this approach, a group of healthcare workers are assigned to be responsible for the care of only patients who are diagnosed to be SARS-CoV-2 positive, thus limiting the number of other healthcare workers to any potential exposure to the virus. ^{Reference de Perio, Dowell and Delaney32,34,Reference Chandy, Nasir, Srinivasan, Klass, Nicolaou and B Babu45,Reference Abad, Barker and Safdar46,Reference French, McKenzie and Coope52,Reference Bonten, Austin and Lipsitch58} According to the Centers for Disease Control and Prevention (CDC), ³⁴ minimizing the number of patient-staff interactions is an effective control measure for reducing SARS-CoV-2 transmission in healthcare facilities. The CDC has recommended that healthcare workers should minimize the number of patient encounters by simultaneously performing some medical procedures or examinations where possible. ³⁴ Additionally, ^{Reference French, McKenzie and Coope52,Reference Bonten, Austin and Lipsitch58,Reference Zhang, Sun, Latour, Hu and Qian61} other studies have reported that developing healthcare teams is an effective measure in minimizing the risk of hospital-acquired infections. There is sufficient evidence suggesting that the cohorting of healthcare workers is effective in minimizing cross-transmission of infectious agents, ^{Reference Cooper, Stone and Kibbler51,Reference Nijssen, Bonten and Weinstein57,Reference Said, Perl and Sears59} and could potentially reduce cross transmission of SARS-CoV-2. Chandy et al., ^{Reference Chandy, Nasir, Srinivasan, Klass, Nicolaou and B Babu45} examined evidence-based measures needed to reduce the transmission of SARS-CoV-2 among patients and staff in healthcare-settings. They reported that cross-covering staff who have been caring for patients with COVID-19 in other units, can lead to intra-hospital transmission, thus, cohorting COVID-19 healthcare teams is imperative. Furthermore, they suggested that multiple teams should be developed as COVID-19 is highly contiguous and if members of 1 team need to go into isolation, the alternative staff members can fill in. They concluded that there are multiple pathways of transmission and formulating healthcare teams can potentially prevent the transfer of SARS-CoV-2 to non-COVID-19 patients and staff. In a systematic review by Abad et al., ^{Reference Abad, Barker and Safdar46} they reported that cohorting patients and healthcare workers is an effective strategy to reduce intra-hospital transmission of infectious diseases. They observed that about 88.5% of studies have reported a significant reduction in the spread of infection when cohorting healthcare workers was implemented with other infectious disease measures such as cohorting patients, and good hand hygiene practices. They concluded that although determining the effectiveness of cohorting healthcare staff can be challenging as typically, other mitigation measures are usually implemented simultaneously, they reported that cohorting staff strengthens the overall infection control strategy.

Environmental controls

Environmental controls, both primary and secondary, are measures that are usually instituted with the intent to reduce the amount of droplet nuclei containing infectious pathogens that may be present in the air. ^{Reference de Perio, Dowell and Delaney32,34,Reference Lai, Tang, Chau, Fung and Li41} The primary environmental controls involve the utilization of mechanical ventilation systems such as hoods, to remove or reduce infectious microorganisms that may be present in the air, whereas the secondary environmental controls involve the use of either the HEPA filtration or/and ultraviolet germicidal irradiation systems to remove aerosol causing diseases agents from the air. ^{Reference Lee81–Reference Morawska and Milton90} According to Lee, ^{Reference Lee81} controlling the direction of airflow in enclosed spaces can potentially reduce the presence of aerosol causing diseases and thus minimize the likely spread of diseases to adjoining spaces. Evidence suggests that SARS-CoV-2 can be transmitted from an infected person to others through respiratory droplets and aerosols, created when an infected person coughs/sneezes, sings, shouts, or talks. ^{Reference Wan, Xiang and Fang11,Reference Krajewska, Krajewski, Zub and Zatoński13,Reference de Perio, Dowell and Delaney32} Thus incorporating environmental control measures that are capable of removing SARS-CoV-2 from the air, into infectious disease control strategies, is important to reduce its spread in healthcare facilities. ^{Reference de Perio, Dowell and Delaney32,34,Reference Somsen, van Rijn, Kooij, Bem and Bonn82} Several studies have demonstrated that the implementation of environmental control measures such as adequate ventilation, installation of air dampers and HEPA filtration systems, the redistribution of airflow in facilities, and regular maintenance of the heating, ventilation and air-conditioning systems are effective mitigation strategies to minimize the spread of nosocomial SARS-CoV-2, ^{Reference Lai, Tang, Chau, Fung and Li41,Reference Somsen, van Rijn, Kooij, Bem and Bonn82,Reference Shajahan, Culp and Williamson89,Reference Saran, Gurjar and Baronia91–Reference Mousavi, Kananizadeh, Martinello and Sherman95} Evidence suggests that adequate utilization of the heating, ventilation, and air conditioning systems in healthcare facilities is imperative to help minimize airborne transmission of SARS-CoV-2. ^{Reference Lai, Tang, Chau, Fung and Li41,Reference Somsen, van Rijn, Kooij, Bem and Bonn82–Reference Saran, Gurjar and Baronia91,Reference Mousavi, Kananizadeh, Martinello and Sherman95} Somsen et al., ^{Reference Somsen, van Rijn, Kooij, Bem and Bonn82} investigated how ventilation levels impact the amount of airborne droplets present at a given time in various spaces, to gain a better insight of airborne transmission in order to suggest appropriate mitigation strategies needed to prevent the spread of SARS-CoV-2. They observed that in spaces with adequate ventilation, the quantity of aerosols present in the air decreased by about 50% within 30 seconds of adequate ventilation, whereas a greater amount of aerosols persist in the air for a prolonged period of time in poorly ventilated spaces. They concluded that poorly ventilated areas could lead to the spread of SARS-CoV-2 via aerosol droplets as they remain suspended in the air for a prolonged period. Consequently, proper ventilation plays a vital role in preventing airborne transmission of SARS-CoV-2 by removing aerosol particles in the air. Lai et al., ^{Reference Lai, Tang, Chau, Fung and Li41} examined different infection control measures implemented at an ophthalmology clinic to minimize the spread of SARS-CoV-2. They reported that adding fresh air dampers to the ventilation system and using high efficiency particulate air filters to purify the air and to remove the infectious droplets, could potentially reduce infectious droplets present in the air, thus lowering the concentration of droplets by redistributing airflow. They concluded that the implementation of this environmental control measure is imperative in preventing the spread of SARS-CoV-2. Saran et al., ^{Reference Saran, Gurjar and Baronia91} also reviewed several heating, ventilation, and air conditioning system guidelines for information on how healthcare facilities could improve or maintain high indoor air quality to prevent the spread of nosocomial transmission. They suggested that, for optimal safety and protection of staff, any suspected or confirmed COVID-19 patient should be admitted in an airborne isolation room with an air exchange rate of at least 6 air exchanges per hour for older facilities, and at least 12 air exchanges per hour for newly built facilities. They reported that guidelines from several professional bodies suggest that all aerosol generating procedures relating to COVID-19 should be performed in well ventilated negative pressure rooms to mitigate airborne transmission. Adjusting the air distribution, air flow rate, and air exchange rates of the heating ventilation and air condition systems in such spaces would potentially minimize infectious particles from reaching non-contaminated spaces. They concluded that the heating ventilation and air condition systems in healthcare facilities could play an integral role to prevent the spread of airborne nosocomial transmission of SARS-CoV-2 and proper utilization and maintenance of such systems should be incorporated in any pandemic management program.

Personal protective equipment (PPE)

Personal protective equipment (PPE) serves as a barrier between the wearer and the environment, to prevent pathogens from entering the body, and has been proven to effectively protect healthcare workers from exposure to various pathogens. ^{Reference de Perio, Dowell and Delaney32,34,Reference Wong, Goh and Tan36,Reference Tomas, Kundrapu and Thota96} Some examples of PPE include surgical masks, N95 respirators, medical gloves, gowns, goggles, and face shields. ^{Reference Tomas, Kundrapu and Thota96} According to Barratt et al., ^{Reference Barratt, Shaban and Gilbert97} it is imperative that every healthcare setting has a well-established PPE program which clearly outlines any hazards that pose illness within the working environment, ensures adequate selection and use of PPE, clearly outlines donning on and off practices, regular testing of PPE for staff, regular inventory check of PPE to determine if they have an adequate amount of supply in case of any emergency, and regular staff training on the use of PPE. The proper use of PPE can potentially prevent self-contamination as well as transfer of infection from person to person, and several studies have established the importance of PPE in protecting healthcare workers and in prevention of the spread of nosocomial SARS-CoV-2 in health care settings. ^{Reference Kalantary, Khadem and Golbabaei98–Reference Suzuki, Hayakawa and Ainai107} However, according to Hoernke et al., ^{Reference Hoernke, Djellouli and Andrews101} it is important for hospital administrators and occupational health and safety departments to understand some of the challenges that frontline workers experience when using PPE, so that when developing pandemic preparedness strategies, they could help implement tailored approaches to address some of staff concerns.

Kalantary et al., ^{Reference Kalantary, Khadem and Golbabaei98} conducted a narrative review to identify the different pathways of exposure to COVID-19 among healthcare workers and on the use of PPE to prevent SARS-CoV-2 transmission. They indicated that healthcare workers are more susceptible to the acquisition of SARS-CoV-2 since they are more likely to be in close contact with infected patients, and reported that aerosol generating procedures such as tracheal intubation, tracheotomy, and manual ventilation, are activities that pose the greatest risk of transmission to healthcare workers. Consequently, they recommended that to ensure adequate protection of staff, healthcare workers should always wear full PPE, including N95 respirators, eye protection, gown, gloves, and aprons during aerosol generating procedures, although regular surgical masks could be used during non-aerosol generating procedures. They concluded that the use of PPE is imperative in protecting healthcare workers from acquiring SARS-CoV-2 and is an effective infection control measure in lowering viral transmission. Tan et al., ^{Reference Tan, Kovoor and Williamson99} reviewed the inconsistencies that are reported in the literature pertaining to the recommended PPE use among surgical staff. They reported that all patients with COVID-19 pose a significant risk to healthcare workers, thus proper use of PPE is deemed necessary in all procedures for optimal protection. They suggested the use of surgical mask, disposable gown, gloves, eye protection, and a head covering during non-aerosol generating procedures and the use of N95 respirators, disposable long-sleeved gown, apron, gloves, eye protection, head covering, and shoe covering for aerosol generating procedures. Furthermore, they suggested that in order to ensure optimal protection and minimize the risk of cross-contamination, all healthcare workers should receive proper training on the donning on and off of PPE and if possible, should appoint a staff member who ensures that all members are donning on and off the PPE in the proper sequence. They concluded that PPE is an important line of defense against SARS-CoV-2 and should be readily available to all healthcare workers. Jamieson et al., ^{Reference Jamieson, Steinberg, Martinello, Perl and Rasmussen100} reviewed the recommended practices on the use of PPE to minimize the risk of SARS-CoV-2 exposure and ensure optimal protection for obstetricians. The main purpose of their study was to inform and guide healthcare workers on selecting the appropriate PPE based on the pathway of exposure. They reported the odds of contracting a respiratory infection (0.09%) with proper and consistent use of gloves, gown, mask, and eye protection, coupled with other infection-control measures such as appropriate donning on and doffing off practices, adherence to proper hand hygiene practices and continual cleaning of high touch surfaces. They concluded that consistent and proper use of PPE in conjunction with adhering to adequate hand hygiene practices are important and effective in reducing the risk of acquiring SARS-CoV-2 infection. Hoernke et al., ^{Reference Hoernke, Djellouli and Andrews101} investigated some of the challenges healthcare workers in the UK experienced regarding the use of PPE during the SARS-CoV-2 pandemic. They observed that several healthcare frontline workers reported inadequate supply of PPE, did not receive proper training in the use of PPE, and there was lack of guidance and protocols on the prolonged use of PPE. Furthermore, staff reported some inherent restrictions with the use of PPE such as difficulties communicating with patients, developing skin reactions, and the discomfort of feeling too hot. They suggested that as a good practice to help minimize PPE fatigue, staff should be encouraged to take breaks. They concluded that the use of PPE is very instrumental to help protect frontline workers from acquiring SARS-CoV-2 infection and in prevention of transmission to colleagues and patients. Furthermore, they emphasized the importance of ensuring adequate supply of PPE, training staff on its proper use, and approaches to combat PPE fatigue. ^{Reference Hoernke, Djellouli and Andrews101}