Applying the precautionary principle to personal protective equipment (PPE) guidance during the COVID-19 pandemic: did we learn the lessons of SARS?

Excerpt

On 24 March 2020, the World Health Organization warned that the “chronic global shortage of personal protective gear is among the most urgent threats to virus containment efforts” in the current coronavirus disease (COVID-19) pandemic.1 In response, actions have been taken by agencies and institutions to conserve current supplies while attempting to procure more personal protective equipment (PPE). Conservation strategies often feature recommendations that suggest limiting higher-level PPE (e.g., N95 masks) to certain clinical situations. This guidance is not supported by reliable data, as uncertainty around severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) transmission mechanisms persist. In clinical decision-making, we rely on the principles of evidence-based medicine (EBM); it is the process by which we generate guidance and set standards for care using high-quality evidence. The current pandemic is challenging this hallmark of medical science, as the evidence required to support recommendations on patient care, healthcare worker protection, and resource use is limited, subject to uncertainty, and is constantly evolving.2 We are dealing with a disease where the sensitivity of diagnostic testing is variable, the symptoms may be vague, the clinical course following infection can be unpredictable, the timing and method of transmission is contested, and a vaccine or treatment is unavailable. That said, during a healthcare crisis, policy makers cannot wait for scientific certainty to make decisions.3 Rather they require alternative approaches to dealing with uncertainty and mitigating risk in decision-making. In this paper, we aim to support decision-makers by examining areas of uncertainty regarding COVID-19, reviewing lessons from previous pandemics (including SARS), and outlining how the precautionary principle can be employed in developing guidance around PPE until more robust scientific evidence becomes available. …