In the aftermath of a pandemic that drove an astounding increase in single-use medical supplies, the inevitable reckoning and potential partnership between infection prevention and the healthcare environmental sustainability movement has accelerated. The search for common ground is at a critical inflection point.
“The safety and sterility of products used in healthcare is of utmost importance, but there must also be a balance between using single-use personal protective equipment [PPE] and products that can be processed for reuse,” says Vincent Hsu, MD, MPH, healthcare epidemiologist and executive medical director for infection prevention for AdventHealth in Orlando. “Regulatory agencies, healthcare institutions, and manufacturers all share responsibility for defining where that balance lies.”
A sustainability advocate who is raising awareness about these issues in infection control circles, Hsu says manufacturers likely will not move from disposable to reusable products without clear demand from the healthcare market.
“Manufacturers have no incentive to switch to reusable because almost none of the end users are asking for this change,” he says. “And it is easier for healthcare providers to discard these reusable items rather than going through the process to ensure the cleaning and reprocessing, which takes time. Unless there is grassroots demand from the end user for the industry to provide equipment that can be easily reprocessed, I believe little to nothing will change.”
Therein lies the problem that underscores the need to elevate awareness. According to an environment advocacy report, the United States is the leading offender in terms of the carbon footprint of its healthcare delivery system. Globally, healthcare generates 4.4% of greenhouse gases, according to the report by Health Care Without Harm.
“The United States health sector, the world’s number one emitter in both absolute and per capita terms, produces 57 times more emissions per person than does India,” the report found.1
Of course, U.S. healthcare damage to the environment goes beyond disposable equipment in the name of infection control. There has been some progress on another primary contributor, off-gases created by the use of anesthesia.
“All anesthetics and inhalants have a carbon impact, but some much more than others, either due to greenhouse gas-trapping potential or because there is significant leakage that occurs, such as with nitric oxide,” Hsu said. “Many large healthcare organizations have already voluntarily started taking steps to reduce or eliminate desflurane, the most potent of the anesthetics from a greenhouse gas standpoint, and to reduce nitric oxide leakage.
“When we did our initial assessment at AdventHealth, we found facilities that had already eliminated or significantly reduced desflurane even before our initiative started. Increasing awareness among anesthesiologists about these effects and measuring the impact of these gases in the environment have both been effective in driving change without any mandate.”
Momentum in the UK
The sustainability movement in the United Kingdom sees infection prevention and control (IPC) as potential key partners but acknowledges that the field’s reliance on disposable PPE also could be viewed as a barrier.
“IPC and sustainability don’t always get along,” says Jon Otter, PhD FRCPath, director of infection control at Guy’s and St. Thomas’ National Health Service Foundation Trust in London. “You might describe IPC as a bit of an enemy of sustainability sometimes — it’s true. We are in the mindset of a single-use linear economy when it comes to materials that we provide for infection prevention in healthcare settings. It makes complete sense to move towards a circular [reusable] economy with some of these items. And I firmly believe we will get there with a bit of time, a bit of investment, and the right collaboration involving IPC as the partner in these discussions.”
According to the Department of Health and Social Care (DHSC) in the United Kingdom, there was a 12-fold increase in single-use PPE over the first three years of the pandemic. “From 25 February 2020 to 31 December 2022, DHSC distributed 25.2 billion items of PPE, predominantly for use by health and social care services in England,” the department reported.2 “This compares with approximately 2.04 billion items distributed between 1 January 2019 and 31 December 2019 to all NHS trusts and some social care organizations.”
During the pandemic, disposable gloves and gowns were being used universally, as PPE use increased in tonnage, Otter said. “It became for every patient contact, not just patients with known COVID,” he said. “You can imagine that we started going through tons and tons of PPE. I think it has changed the culture toward PPE and people have become over-reliant on it.”
The manufacture and disposal of PPE as medical waste undermines efforts to reduce carbon emissions and greenhouse gases that contribute to global warming. “Each individual item of PPE has a measurable carbon footprint,” Otter says.
Reducing the volume of single-use gloves, for example, would help the environment but increase reliance on high compliance with hand hygiene, which historically has been a challenge. Of course, glove use still carries risk because workers sometimes go from task to task and patient to patient without changing them.
“You will see a person walking around wearing gloves within about 10 seconds of being on the ward,” Otter said. “I ask, ‘Why are you wearing those gloves, what’s the logic?’ If somebody can explain the logic for wearing gloves, I’m generally happy with that. As long as they’ve thought about it.”
The hospital has a “glove or no glove” campaign to encourage healthcare workers to think about whether they can leave hands uncovered and frequently wash them. “We want to prompt people to think about whether they need to use gloves, but not be so proscriptive about when you should or when you should not,” he says.
The University College London Hospitals (UCLH) reminds healthcare workers that nonsterile disposable gloves are not required when treating noninfectious patients.
According to UCLH, staff are not expected to wear gloves if there are no risks of infection or risk of body fluid exposure when:3
• taking patients’ vitals (e.g. blood pressure, temperature etc.);
• examining or touching a patient;
• assisting a patient with food and drink;
• giving vaccinations;
• administration tasks near a patient (e.g., answering the phone, using the computer);
• moving a patient’s belongings.
• tidying the bedspace.
In some ways, this issue mirrors the classic conundrum of antibiotic use: the physicians’ choice to treat the patient in front of them at the potential risk of endangering the public by selecting out drug-resistant pathogens. Infection preventionists oversee PPE and isolation precautions to protect both patients and healthcare workers, but the manufacture and disposal of these materials contributes to the larger public health threat of climate change.
However, there is growing momentum in the United Kingdom — and ongoing efforts in the United States — to address the environmental component of infection control. (See “Environmentalists Seek Common Ground with IPs.”)
“How can we challenge ourselves to keep things safe but also to make significant sustainability and environmental gains?” Otter said. “If we don’t, we’re sleepwalking toward disaster. That much is clear. We in healthcare, and particularly within IPC, have an important role to play in ensuring that things are done and that they’re done right.”
Otter spoke at a recent webinar held by the Association for Professionals in Infection Control and Epidemiology (APIC). The webinar is part of an overall movement toward “greater conscientiousness” of the effect of the environment on the health, well-being, and continued survival of humanity, says Tania Bubb, PhD, RN, CIC, FAPIC, APIC president.
“Our profession also seeks to reflect, deliberate, and find alternative ways to contribute toward sustainable efforts,” Bubb says. “This begins with first learning how our individual and combined practices affect the environment. These sessions are to raise awareness and begin the conversations needed to take more deliberate actions as a profession.”
Glove Workers Living in Shipping Containers
Also speaking at the APIC webinar was Mahmood Bhutta, DPhil, FRCS, a professor at Brighton & Sussex Medical School in the United Kingdom. Bhutta raised compelling ethical questions in arguing that a “throwaway” medical economy is enabling harsh labor practices in Asia to meet the demand for gloves, gowns, masks, and single-use devices.
Bhutta showed slides of migrant workers working in glove factories in Malaysia, workers from Nepal and Bangladesh and other impoverished areas who are promised lucrative jobs if they pay the average $2,500 recruitment fee. They then work under harsh conditions and are bound to a facility until they pay back the recruitment fee, which they typically take out loans to pay.
According to a study by Bhutta and colleagues that included a survey of approximately 1,500 of these workers and interviews with 11 of them, the pandemic required workload increases and a reduced ability to take breaks.4
At one medical glove production company, workers were housed in shipping containers, with many sharing limited toilets and hygiene areas. “They work 12 to 13 hours every day, every single day,” Bhutta said. “Their lives are difficult. They feel indebted because of all the money that they’ve paid. Their entire existence for three years was to live in shipping containers and be transported to a factory to work there and go back to the shipping containers. They typically have their passports confiscated so they cannot leave. [In our report] you can see all the evidence that this is forced labor.”
Comments from individual medical glove workers in the report include this one, “If I started all over again, I couldn’t do anything different than this. I was desperate for work and income.”
Some U.S. companies have stopped working with such companies, but there is a lot more to be done to address this unintended consequence of insatiable PPE demand during the pandemic, Bhutta said.
“There is increasing recognition in the business community that working conditions overseas must be consistent with ethical standards, and healthcare is no exception,” Hsu says. “It can get complicated when discussing which stakeholders are primarily responsible for raising this issue, as the supply chain — from manufacturer, to distributor, to healthcare facility, to end-user — is complex. Nonetheless, a thoughtful discussion should occur between all healthcare stakeholders.”
Reducing the use of disposable gloves in healthcare could help lower the demand for rapid production in poor working conditions overseas. Otter thinks that reducing glove use is the “win-win” that could help forge a partnership between infection control and environmental sustainability.
“Even when we’re delivering contact precautions, we don’t need to wear gloves unless there is going to be some body fluid exposure risk, in which case we need to make a risk assessment and wear gloves on that basis,” Otter said. “That’s going to be a ‘step change’ for PPE and IPC. It’s going to be a step change for people on the wards.”
A Bridge Too Far
Gloveless contact precuations might be a bridge too far for many U.S. hospitals, particularly because it is contrary to recommendations by the Centers for Disease Control and Prevention’s (CDC) Healthcare Infection Control Practices Advisory Committee (HICPAC).
“If appropriate hand hygiene takes place, there should not be a concern of transmission of pathogens from one patient to the next,” Hsu says. “But the key would be ensuring appropriate hand hygiene in the correct circumstances. The CDC HICPAC guidelines still recommend gloves for patients in contact isolation, based on studies done many years ago. If more recent studies can demonstrate appropriate hand hygiene does not increase transmission risk and if facilities can ensure appropriate adherence, then we can get traction for removing glove use. But that remains a big ‘if.’”
In general, gloves can provide a false sense of security to staff, who feel protected and then may not perform hand hygiene when the gloves are removed, Otter said. Gloves tend to be worn for too long, way beyond the duration of the immediate task for which they were selected, he added.
“I think it’s important to accept some gray areas in decision-making about when and when not to wear gloves,” Otter said. “But, overall, if I can get people to think [whether they need gloves or not], I’m certain that that will reduce the overall amount of gloves that we use.”
Indeed, the ongoing program set an initial goal of a 30% reduction in glove use and had reached 23% as this report was filed. Infection preventionists in the United States should join their organization’s sustainability program and brainstorm about ways they can maintain quality care while reducing carbon emissions.
Although some still are pushing for a full standard, the Joint Commission is offering a Sustainable Healthcare Certification for U.S. hospitals that voluntarily pursue environmental sustainability efforts in a program that began on Jan. 1, 2024. According to the Joint Commission, healthcare represents about 9% of the nation’s carbon footprint.
The voluntary certification program “provides a framework to help organizations begin, continue, or expand their decarbonization efforts and to receive public recognition for their commitment and achievements in contributing to environmental sustainability,” the Joint Commission stated.5 “Decarbonization also is an imperative for improving healthcare equity and patient safety, as the individuals least able to compensate for the effects of the climate are already burdened with adverse social determinants of health.”
The U.S. branch of Health Care Without Harm, a global organization, is urging the Joint Commission to make the program mandatory as an accreditation standard.
“It is absolutely a step in the right direction, but we don’t think that it is sufficient,” says Emily Mediate, MSc, MPP, director of climate and health in the United States for the organization. “Mandates are what we need in this critical moment. So, we’re pushing oversight bodies, not just the Joint Commission but the Centers for Medicare and Medicaid Services to require healthcare systems to complete an emissions inventory and to be putting in a plan to reduce their emissions. When regulations are adopted, there also needs to be some technical assistance, especially in rural hospitals across the country.”
There may be enough awareness building in the United States for the Joint Commission to leave the policy as voluntary and let hospitals respond to the “peer pressure” of those moving ahead on sustainability initiatives, Hsu says.
“Healthcare is not unlike other industries in that it is competitive and doesn’t want to be viewed as a holdout when community standards change,” he says. “I have seen significant movement in this space in just the past year, which makes me more optimistic that, over a relatively short time span, the combination of published data along with the recommendations of professional societies and the positive experiences of many in the healthcare industry to reduce carbon emissions will obviate the need for the Joint Commission to [make this a] standard. Peer pressure can do a lot.”
REFERENCES
- Health Care Without Harm. Health care’s climate footprint. Executive summary. Published September 2019. https://noharm-global.org/sites/default/files/documents-files/5952/HealthCaresClimateFootprint_exec_summary.pdf
- Gov.UK. Experimental statistics – personal protective equipment distributed for use by health and social care services in England: Quarterly update to 31 December 2022. The Department of Health and Social Care. Published Jan. 12, 2023. https://www.gov.uk/government/statistics/ppe-distribution-england-quarterly-update-to-31-december-2022/experimental-statistics-personal-protective-equipment-distributed-for-use-by-health-and-social-care-services-in-england-quarterly-update-to-31-dece
- University College London Hospitals. Gloves off for better safety and a greener NHS. Published July 27, 2023. https://www.uclh.nhs.uk/news/gloves-better-safety-and-greener-nhs#
- Bhutta M, Bostock B, Brown J, et al. Forced labour in the Malaysian medical gloves supply chain before and during the COVID-19 pandemic: Evidence, scale and solutions. Modern Slavery & Human Rights Policy & Evidence Centre. Published July 2021. https://www.bsms.ac.uk/_pdf/about/forced-labour-in-the-malaysian-medical-gloves-supply-chain-full-report-july-2nd-2.pdf
- The Joint Commission. The Joint Commission announces Sustainable Healthcare Certification for U.S. hospitals. Published Sept.18, 2023. https://www.jointcommission.org/resources/news-and-multimedia/news/2023/09/sustainable-healthcare-certification-for-us-hospitals/
In the aftermath of a pandemic that drove an astounding increase in single-use medical supplies, the inevitable reckoning and potential partnership between infection prevention and the healthcare environmental sustainability movement has accelerated. The search for common ground is at a critical inflection point.
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content. TESTING
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content