Effective Anti-Fogging Agent for Glasses and Face Shields in the Treatment of Ebola in Uganda: Implications for Healthcare Worker Safety and Patient Care

David Francis Olebo1*, Gerald Kanyomozi2, Jacqueline Nalikka3 and Moses Asiimwe4

PCR: Polymerase Chain Reaction; MoH: Ministry of Health; MUWRP: Makerere University Walter Reed Project; IDI: Infectious Diseases Institute; WHO: World Health Organization; COR: Correlation; AOR: Adjusted Odds Ratio.

Introduction

Ebola patients are highly infectious and end up being critically ill requiring the need for intensive clinical care in the isolation treatment Centres. This has made frontline healthcare workers to be at risk of aerosol exposure and infection during their care. Therefore, the use of effective personal protective equipment (PPE) is paramount and the World Health Organization (WHO) recommended the use of; masks, gloves, coveralls, face shields, aprons, and face shields in their management [1, 2]. Eye protection for procedures with a reasonable probability of infection/injury is paramount. Eye protection (goggles) and face shields are made of plastic material and play an important role in preventing exposure of eyes to aerosols and pathogens and serve as an important barrier to breaking the chain of infection [3]. Despite the use of protective Goggles and Face shields (GFS), health workers have continued to fog and in the Ebola outbreak in West Africa, healthcare workers were 21 to 32 times more likely to be infected with Ebola than the general population [4] and by the time the outbreak was over Guinea had lost all in total; Doctors, Nurses and Midwives 5317, Liberia 946 and Sierra Leone had lost 1074. This would be attributed to a large number of patients they had to attend and the PPE like googles and face shields could fog within a short time posing a risk of exposure to the health workers who ended up contracting and dying of Ebola as they tried to save the patients Evans DK, et al. [5] in a systematic review on 94 articles related to 22 outbreaks published before 27 December 2017, the health care workers infections to Ebola was 0.6% to 92%. It was consistent throughout the outbreaks and the health worker’s exposure would be attributed to Fogging of their google [6]. However, the WHO updated guidelines on use of protective goggles and face shields emphasized the role of eye protection for healthcare workers involved in the management of patients with highly infectious diseases like Ebola but the guidelines do not highlight need for use of antifogging agents on the goggles or face shields [7]. In the recent Ebola pandemic in Uganda with high morbidity of critically ill Ebola patients overwhelmed the healthcare teams managing cases requiring more contact time for the healthcare workers to attend to the patients yet putting on PPE like goggles and face shields shields recommended by WHO fog in the short time, limiting the work of the health care workers in the overwhelming Ebola Treatment Centres with critically ill patients. Fogging hinders effective patient care hence increased mortality out come on the patients, and impaired vision with increased risk of failure to carry out aerosol generating procedures and contracting the infection. Fogging has been due to improper fitting mask, which redirects the warm exhaled gases upward instead of forward. This warm water vapor in exhaled breath condenses on the relatively cold lenses of the goggles and causes fogging [8]. This observational study therefore was seeking to establish an effective antifogging agent, side effects associated with fogging, and impact of fogging to patient’s health outcome in the Ebola treatment Centres with the over whole aim of coming up with an effective antifogging agent to be used to improve the time health care workers spend attending to critically ill Ebola Patients which was achieved.

Results

Demographic Characteristics

Table 1 shows 21 out of 30 health care workers took part in the study from FPRRH-ETC a majority; 47% of the participants were 20-30 years old, 57.1% were females, 42.9% had university bachelor’s degree, and 33.3% were Nurses while 71.4% of them had 1-2 years’ experience in working in the isolation units. We also found out that FPRRH-ETC had 12-hour shifts; day duty and night duty with majority 42.9% of them donning 3 to 4 times in the shift and 28.6% of them donned 5 to 6 times in the shift. The study highlights that health workers were educated, with a lot of experience in managing highly infectious diseases but overwhelmed with work in that they had to don up to 6 times in a single shift.

Source: Primary field data 2022. Table 1: Demographic characteristics of the participants (n=21).

Effectiveness of Antifogging Agents

The Table 2 demonstrates the effectiveness of antifogging agents. Among participants who applied liquid soap to their glasses and experienced no fogging, 66.7% of them were expected to spend 1-2 hours and 3-4 hours in the red zone, with each group accounting for 33.35%. Those who fogged after 4 hours constituted 9.5% and were expected to spend 3-4 hours performing tasks. Additionally, those who fogged after 3 hours comprised 9.5%, with 4.75% of them expected to spend 1-2 hours and 3-4 hours, respectively. Finally, 14.3% experienced fogging after 2 hours, and all of them were expected to spend 1-2 hours performing their tasks. These results were statistically significant, indicating a positive correlation (COR 0.836; AOR 0.223; P < 0.001). These was in line with the study conducted on sulfonated polymer-coated eyewear in which those that did not use coated eyewear fogged their duration was 2 hours Keschner YG, et al. [11] and antifogging comparison study [12].

For Participants who applied alcohol 80% concentration. Among those who fogged within 1-20 minutes, 76.2% of them were expected to take 1-2 hours to complete their tasks, and 42.85% were expected to spend 3-4 hours on assigned tasks. Among those who fogged within 21-40 minutes, accounting for 23.8%, 19% were expected to take 1-2 hours to complete their tasks, and 4.8% were expected to spend 3-4 hours. This result was statistically significant, indicating a negative correlation (COR -0.475; AOR 0.048; P 0.030). These was in line with the study that compared the antifogging agents [9, 12].

For participants who did not apply any antifogging agent, the majority (95.2%) experienced fogging within 1-20 minutes. Among them, 47.6% were expected to take 1-2 hours to complete their tasks, and the same proportion (47.6%) was expected to spend 3-4 hours on their tasks. A minority experienced fogging within 21-40 minutes, and all of them were expected to take 1-2 hours to complete their tasks. This result was not statistically significant and showed a negative correlation (COR -0.138; AOR -0.005; P 0.552). These was in line with the study conducted on anti-fog polymer coating [9, 11, 12].

Source: Primary field data 2022 Table 2: Level of Effectiveness of Antifogging Agents (n=21).

Impact of Fogging

The Figure 1 shows over 90% of the participants who fogged could not see and stopped working that had a negative impact on their work (ref-figure 1). Fogging puts the HCWs at risk of falling hence fractures [13, 14].

Click to enlarge

Source: Primary field data 2022. Figure 1: Impact of Fogging to Patients Care in ETC (n=21).

Side Effects of Fogging

The Figure 2 shows reported side effects that were specific to only health care workers who fogged with 53% of them reporting headache, 43% reporting dizziness and only 4% reporting anxiety. These would be attributed to low oxygen circulation in the brain resulting from fogging and it was in line with the study that assessed the physiological effects of PPE among healthcare workers [14, 15, 16, 17].

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Source: Field Data 2022. Figure 2: Reported Side Effects that were Specific to Health care workers who fogged (N=42).

Discussion

Eye protection has been established as an essential and mandatory component of personal protection for health care workers attending to patients with highly contagious infections in high containment areas such as the Ebola treatment Centres [18]. The risk of transmission of Ebola virus disease among health workers is so high due to the nature of activities in an ETC and the infectiveness of the Ebola virus. However, fogging of eye shields and goggles remains a challenge and poses additional risks to health workers. Fogging obstructs clear vision for the health care worker to perform tasks in an ETC, and the need to adjust the goggles to restore vision is one of the most risky manoeuvres that can lead to potential transmission of the Ebola virus [19].

This study aimed to determine a more effective antifogging agent to be used by health care workers who are taking care of patients with highly contagious infections such as Ebola virus disease. The study also sought to establish the side effects of fogging and the impact of fogging on clinical care of patients in an ETC.

Results of this study show that the use of surfactant- based solutions in form of liquid soap offered superior benefits to health care workers in Ebola treatment Centres. The use of liquid soap delayed fogging and thus increased the time spent in an ETC for each health care worker. This was of particular benefit to the treatment teams who were usually stretched in terms of human resource capacity, and reduced the number of dangerous incidents among health care workers. This finding is in line with a study conducted by T. Varshney and others who found out that washing soap application on goggles and face shields offered antifogging properties for up to six hours [9].

The fogging of eye goggles and face shields reduced the ability to provide critical care needed by the patients. This is because of reduced vision that was experienced by health care workers who fogged. Saskia Den Boon and colleagues noted that impaired visibility was a challenge to health care workers, particularly those who used goggles. These was inline with a study that used washing soap [20].

Conclusions

Despite the small number of worker studies, Liquid Soap is a superior and effective antifogging agent for use in the isolation Treatment Centres more so in the resource limited setting. Health Care Workers who did not use liquid soap, most of them spent less time performing their tasks. The side effects associated with fogging were headache and dizziness. No health care Ebola infections were registered in our Ebola Treatment Centre and all the Health care workers who took care of Ebola patients applied liquid soap on their glasses and were able to complete all their tasks in ETC with most of them not fogging. This study recommends WHO and MoH to include in their IPC guidelines the use of liquid soap as antifogging agent for the glasses and face shields during donning in order to improve level of care and health care worker safety in the Isolation Centres.

Acknowledgement

We acknowledge the dedication and resilience of healthcare workers at Fort Portal Regional Referral Hospital Ebola Treatment Centre. Our gratitude also goes to the Ministry of Health (MOH) Uganda, particularly recognizing the Clinical Care sub-pillar at the National task Force. Additionally, we acknowledge MUWRP and IDI Management. We also extend our heartfelt thanks to well-wishers and friends for their support and contributions in the control of the outbreak.

Funding

This work was funded by the authors themselves and no external individual or organization funded it.

Competing Interests

The authors do not have any conflict of interest in this research.

Ethics Approval

The research work was approved by Fort Portal Regional Referral Hospital Management and informed consent from the participants.

Data Availability Statement

All the relevant data in this study have been analyzed and reported in the article but data set can be availed on request.

Supplemental Material

Not Applicable.