How Does Surgical Gloves Impact Our Enviroment - T-Tees - Your Answers Await, Life's Questions Unraveled

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Zhang et al. highlight the profound environmental impacts associated with high volumes of single-use personal protective equipment (PPE), as a consequence of the COVID-19 pandemic. (1) Changes are urgently required in the manufacture, use and disposal of PPE if we are to mitigate these impacts. Zhang et al.’s argument concerns plastics in commonly used items of PPE with a particular emphasis on waste, while we wish to draw attention to the crucial steps that should be considered prior to disposal. To optimise the sustainability of PPE and minimise the generation of waste, our approach should incorporate the “5Rs”: reduce, reuse, recycle, research and rethink. (2)

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Reduction in the use of PPE is the most effective strategy to minimise its environmental impacts. Whilst the use of PPE is required in many clinical settings during the pandemic, measures to reduce unnecessary and repeated donning and doffing such as having “clean” runners to fetch equipment and drugs are both simple and effective. In non-clinical settings, especially hospitality and service, there has been an increase in so-called “hygiene theatre”, the (conspicuous) wearing of PPE such as nitrile gloves. A recent study indicates that the global warming impact of a single glove is 26 grammes of CO2 equivalent; on this basis, every box of 100 gloves is equivalent to driving 20 miles in a standard petrol car. (3) Organisations should take steps to focus the deployment of PPE to where it is required for safety, rather than agreeing to its use for reasons of public image. Furthermore, the extensive use of plastic packaging (for example, disposable visors supplied in both a plastic bag and with a plastic film on both sides of the visor) should be curtailed.

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Though Zhang et al. concentrate on single-use face masks in their editorial, reusable alternatives are used widely within the NHS. These include respirator masks which can be cleaned after use, with the only disposable part being the filters which are routinely changed after several months. These do, however, suffer from issues of user discomfort and difficulties with communication. Powered air purifying respirators are generally more comfortable and allow the wearer’s face to be seen, aiding communication among the team and with the patient, however they are more complex and expensive than masks so may not be suitable for every situation. Reusable surgical gowns have been adopted in many centres; these are laundered before returning to circulation, reducing the environmental impact by around 65% compared to disposable gowns. (3)

Recycling of single use PPE presents several challenges. These include issues with separating mixed materials and the potential risks of contamination as a consequence of handling infectious material. In order to tackle these issues, the manufacture of single use PPE needs to be re-examined to emphasise the importance of using single recyclable materials which can ideally be fed back into a closed loop recycling system. However, if this is to succeed, it must be complemented by regulatory approvals and systems that facilitate the safe recycling of equipment that has been used in the clinical setting.

Epidemics and pandemics are anticipated to occur more frequently in the future, and as the COVID-19 pandemic subsides we must maintain a research focus on PPE in order to reduce its contribution the already substantial environmental impacts of healthcare. This may include the development of reusable equipment that better suits healthcare work, and the investigation of the roles of plastic alternatives, such as starch-based biopolymers, in the manufacture of PPE.

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The scientific basis for PPE use needs to be continually re-examined as the evidence base for transmission and contamination improves. For example, there is increasing evidence that SARS-CoV-2 transmission is predominantly airborne, with relatively low risks of surface transmission providing that effective handwashing is maintained. (4) However, ‘contact precautions’ such as gloves, aprons and gowns have been a constant feature of PPE policy since the start of the pandemic. (5) Locally, we have noted an increasing number of healthcare organisations opting to reduce the use of these items despite Public Health England’s guidance remaining unchanged. This suggests that the national guidance requires review in order to maintain credibility in light of emerging evidence.

It seems incredible that over the last year, we have developed multiple vaccines for COVID-19 but have not yet developed more sustainable PPE. We agree with Zhang et al. that greener manufacture, use and disposal of plastic PPE are urgent priorities but would add that increasing our understanding of how we source and utilise PPE in our healthcare systems through detailed life-cycle assessments is equally important. Applying the “triple bottom line” approach, incorporating environmental, social and economic considerations, should be at the heart of all decisions if we are to meet a ‘net zero’ NHS. (6)

References:

1. Zhang EJ, Aitchison LP, Phillips N, Shaban RZ, Kam AW. Protecting the environment from plastic PPE BMJ 2021; 372 :n109 2. Hutchins DCJ & White SM. Coming round to recycling. BMJ 2009; 338: b609 3. Rizan C, Reed M, Bhutta MF. Environmental impact of Personal Protective Equipment distributed for use by health and social care services in England in the first six months of the COVID-19 pandemic. medRxiv 2020; doi: https://doi.org/10.1101/2020.09.21.20198911 4. Zhang R, Li Y, Zhang AL, et al. Identifying airborne transmission as the dominant route for the spread of COVID-19. Proc Natl Acad Sci USA 2020; 117: 14857-63 5. Public Health England. COVID-19: infection prevention and control guidance. 21 January 2021. https://assets.publishing.service.gov.uk/government/uploads/system/uploa… 6. National Health Service. Delivering a ‘Net Zero’ National Health Service. London: NHS England and NHS Improvement 2020

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