A position statement and practical guide to the use of particulate filtering facepiece respirators (N95, FFP2, or equivalent) for South African health workers exposed to respiratory pathogens including Mycobacterium tuberculosis and SARS-CoV-2.

SUMMARY: Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is transmitted mainly by aerosol in particles <10 µm that can remain suspended for hours before being inhaled. Because particulate filtering facepiece respirators ('respirators'; e.g. N95 masks) are more effective than surgical masks against bio-aerosols, many international organisations now recommend that health workers (HWs) wear a respirator when caring for individuals who may have COVID-19. In South Africa (SA), however, surgical masks are still recommended for the routine care of individuals with possible or confirmed COVID-19, with respirators reserved for so-called aerosol-generating procedures. In contrast, SA guidelines do recommend respirators for routine care of individuals with possible or confirmed tuberculosis (TB), which is also transmitted via aerosol. In health facilities in SA, distinguishing between TB and COVID-19 is challenging without examination and investigation, both of which may expose HWs to potentially infectious individuals. Symptom-based triage has limited utility in defining risk. Indeed, significant proportions of individuals with COVID-19 and/or pulmonary TB may not have symptoms and/or test negative. The prevalence of undiagnosed respiratory disease is therefore likely significant in many general clinical areas (e.g. waiting areas). Moreover, a proportion of HWs are HIV-positive and are at increased risk of severe COVID-19 and death. RECOMMENDATIONS: Sustained improvements in infection prevention and control (IPC) require reorganisation of systems to prioritise HW and patient safety. While this will take time, it is unacceptable to leave HWs exposed until such changes are made. We propose that the SA health system adopts a target of 'zero harm', aiming to eliminate transmission of respiratory pathogens to all individuals in every healthcare setting. Accordingly, we recommend: the use of respirators by all staff (clinical and non-clinical) during activities that involve contact or sharing air in indoor spaces with individuals who: (i) have not yet been clinically evaluated; or (ii) are thought or known to have TB and/or COVID-19 or other potentially harmful respiratory infections;the use of respirators that meet national and international manufacturing standards;evaluation of all respirators, at the least, by qualitative fit testing; andthe use of respirators as part of a 'package of care' in line with international IPC recommendations. We recognise that this will be challenging, not least due to global and national shortages of personal protective equipment (PPE). SA national policy around respiratory protective equipment enables a robust framework for manufacture and quality control and has been supported by local manufacturers and the Department of Trade, Industry and Competition. Respirator manufacturers should explore adaptations to improve comfort and reduce barriers to communication. Structural changes are needed urgently to improve the safety of health facilities: persistent advocacy and research around potential systems change remain essential.

Fear and COVID-19: Experiences on the ground

The impact on services and supply lines of the epidemic and various forms of lockdown is covered in preceding presentations. I will focus more on the personal impact of the COVID-19 pandemic on HIV-positive patients, families, and health workers. There is little research on social impacts, especially from resource-poor environments, so this relies somewhat on personal experience, colleague and patient anecdote, and (often fragmented) media reports, largely from the Southern African region. Reports from patients, and substantiated by informal donor monitoring, suggest large numbers of patients endured feardriven antiretroviral interruptions, conservatively estimated at over a million patients (around 20%) in South Africa, possibly worse in countries with weaker supply systems. HIV testing, antiretroviral initiations, and male circumcision programmes ceased to operate for much of 2020. Fear was voiced by patients and families on several fronts: Many countries used iron-fisted security approaches (and used to quash political opposition, as happened in Uganda), with over 340 000 people arrested in South Africa in 2020 alone for lockdown offences, with footage of soldiers brutally forcing people off streets into crowded shacks. Many patients reported fear of being arrested while collecting their medication. Limited and crowded public transport, as well as distrust of clinic infection control measures, were cited for non-attendance. Foreigners were excluded in many programmes from supportive services (in South Africa, with many migrants, excluded foreigners from food parcels and unemployment insurance). Initial reports of exclusion of foreigners from vaccine programmes have been firmly reversed in South Africa, triggered by the recognition of rising vaccine nationalism in richer countries. The impact on health care workers has been widely reported in the media around the globe, spanning experiences of illness and death of colleagues triggering acute workforce shortages, to burnout and empathy fatigue. Shortages of protective equipment and labour demands for higher-than-necessary levels of equipment again speak to occupational fear reminiscent of HIV transmission concerns in the very early 80s. There is some evidence that health systems and health workers demonstrated remarkable increased resilience in subsequent ''2nd waves'' as experience with protections and increases in patient loads improved.

Long-COVID: An evolving problem with an extensive impact

Persistence of symptoms or development of new symptoms relating to SARS-CoV-2 infection late in the course of COVID-19 is an increasingly recognised problem facing the globally infected population and its health systems. 'Long-COVID' or 'COVID long-haulers' generally describes those persons with COVID-19 who experience symptoms for >28 days after diagnosis, whether laboratory confirmed or clinical. Symptoms are as markedly heterogeneous as seen in acute COVID-19 and may be constant, fluctuate, or appear and be replaced by symptoms relating to other systems with varying frequency. Such multisystem involvement requires a holistic approach to management of long-COVID, and descriptions of cohorts from low- and middle-income countries are eagerly awaited. Although many persons with long-COVID will be managed in primary care, others will require greater input from rehabilitation medicine experts. For both eventualities, planning is urgently required to ensure that the South African public health service is ready and able to respond.