Comparative Study upon using Sanitizers and Personal Protective Equipment during COVID-19 Pandemic between Saudi and Egyptian Health Care Providers

During coronavirus disease (COVID-19) pandemic hand hygiene was one of the most essential preventive practice health care workers (HCWs) due to their frequent washing their hands with sanitizers. Wearing gloves after using hand sanitizers may cause skin irritation and dryness. Original Research Article Mahmoud et al.; JPRI, 33(13): 61-73, 2021; Article no.JPRI.65673 62 Wearing masks were effective in reducing the probability of infection with COVID-19, but wearing them for long time cause many problems. This paper was aimed to compare between Saudi and Egyptian HCWs upon using sanitizers and personal protective equipment (PPE) during COVID-19 pandemic. Data was collected through a well-structured questionnaire, among Saudi HCWs (online) and Egyptian HCWs through paper questionnaire interview. The questionnaire consists of 23 questions about Socio-demographic, types of masks, gloves and sanitizers they used during their works. It includes the adverse skin reactions on hands and face upon using PPE for long periods during COVID 19 pandemic. Our results revealed that most of Saudi & Egyptian HCWs wearing surgical masks (57.8% & 63.6%), > N95 (12.9% &18.2%), using latex surgical gloves (44.9% & 56.8%), > plastic gloves (11.1% &18.2%) respectively. The most affected area from wearing PPE are hands (49.8% & 54.5%) followed by Auricular area (44% & 40.9%), nasal bridge (28.9% & 22.7%), check (16.9% & 13.6%), whole face (15.6% & 25%) among Saudi & Egyptian HCWs respectively. About 70% of Egyptian HCWs from our participants used alcohol 70% in form of gel as sanitizer which was significantly higher than Saudi HCWs (59.1%). While no significant differences were found from using other sanitizers such as liquid alcohol 70% or Dettol. The most adverse reaction due to using sanitizers was skin dryness (55.1% & 63.6%) among Saudi & Egyptian HCWs respectively. We can conclude that significant increase was found among HCWs in Egypt either in wearing surgical and N95 masks or in wearing surgical and plastic gloves when compared to Saudi HCWs. According to the side effects on hands and face due to wearing PPE among HCWs either from KSA or Egypt, there were some variations by increase or decrease in the percentages. The most adverse reaction due to using sanitizers (specially alcohol 70% in form of gel) was skin dryness.


INTRODUCTION
In December 2019, unexpected outbreak happened in Wuhan city,that later on had been known as COVID-19 by World health organization [1]. The routes of COVID-19 transmission are via droplet, fomites and airborne transmission of droplet nuclei [2]. However, during the COVID-19 pandemic, HCWs were at high risk of COVID-19 transmission due to the direct contact with COVID-19 patients. As a consequence, HCWs had to wear PPEs such as N95 masks and latex gloves for many hours, wash their hands using sanitizers [3]. On other hand, the use of PPEs for long period may lead to increased risk of adverse skin reactions such as dryness, tenderness, itching, burning/pain and others [4][5][6]. Medical mask is one of the most important PPEs which prevent the spread of respiratory tract infections by reducing the probability of airborne droplets transmission by covering the nose and mouth. Surgical masks and N95 have been used also. On the other hands, N95 have been effective in blocking 95% of airborne particles [7]. Some authors found that N95 mask was the most type that caused a serious adverse skin reaction because HCWs were tie the mask very tightly and press the metal clip hard. N95 mask when used for long period reported adverse reactions including nasal bridge scarring, itching, skin damage, dry skin, acne, and rash [5]. Another study in Singapore found that Using gloves regularly result in high prevalence of dry skin, itching, and rash. All were using rubber gloves, none reported skin reactions with the use of plastic gloves. There were no significant differences in adverse skin reactions due to sex, race, or profession. However, staff who reported dry skin and itch were younger compared with staff who did not [4]. During COVID-19 pandemic hand hygiene was one of the most essential preventive practice HCWS due to their frequent contact with patients, they were washing their hands more frequently with water and soap and using sanitizers [8]. Hand hygiene products contain an antiseptic to inactivate microorganisms and/or suppress their growth over the skin temporarily [2]. the CDC (centers for disease control and prevention) recommends probably and frequently hand washing either with soap and water or if soap not available, hand sanitizer containing at least 60% alcohol [9]. However, there were many reports of increased incidence of getting dermatologic problems such as dryness and other skin problems due to frequent hand washing and using of sanitizers among HCWs [10]. Alcohol-based hand sanitizer it has been used as a part of hand hygiene, it can be in form of liquid, gel or foam that contains either ethanol or isopropanol. As a result of COVID-19 pandemic, CDC recommends HCWs to use Alcohol-based hand sanitizers that contain 60%-95% alcohol. However, wearing gloves after using hand sanitizers may cause skin irritation and frequent use of sanitizers cause dryness of hands [9,11]. The aim of this research is to compare between Saudi and Egyptian HCWs upon frequent usage of masks, gloves and sanitizers during COVID-19 pandemic and to clarify their adverse skin reactions.

Study Design
The Study was conducted through Cross sectional study design. It was carried out through well designed questionnaire among health care providers both in Saudi Arabia (on google and through paper questionnaire in Egypt in Clinics among health care providers for 2 months starting from first of November 2020. The questionnaire consists of 23 questions about Scio-demographic, types of masks, gloves and sanitizers that used by health care workers in the clinics, hospitals, and medical centers. It includes the adverse effect upon using PPE and sanitizers for long time on skin and face during pandemic.

Sample Collection
This study was carried out among health care workers in Saudi Arabia (through questionnaire on Google Drive, number of participants were 252 HCWs) and in Egypt medical polyclinics (through paper questionnaire, number of based hand sanitizers that contain 95% alcohol. However, wearing gloves after zers may cause skin irritation and frequent use of sanitizers cause dryness of hands [9,11]. The aim of this research is to compare between Saudi and Egyptian HCWs upon frequent usage of masks, gloves and 19 pandemic and to The Study was conducted through Crosssectional study design. It was carried out through well designed questionnaire among health care providers both in Saudi Arabia (on google Drive) and through paper questionnaire in Egypt in Clinics among health care providers for 2 months starting from first of November 2020. The questionnaire consists of 23 questions about demographic, types of masks, gloves and health care workers in the clinics, hospitals, and medical centers. It includes the adverse effect upon using PPE and sanitizers for long time on skin and face during COVID-19 This study was carried out among health care workers in Saudi Arabia (through questionnaire on Google Drive, number of participants were 252 HCWs) and in Egypt medical polyclinics (through paper questionnaire, number of participants were 176 HCWs). All par were provided with clear and easy understand information about the research paper in order to allow them to make an informed and voluntary decision about their participation. Filling the questionnaire was considered their agreement about participation. Person selection to participate in the research was conducted through convenience sampling, non technique.

Inclusion Criteria
All participants from both genders should be from health care providers who are working in hospitals, medical clinics and health care centers during first of November 2020 till end of December 2020. The age of participants from 18 years-old and above.

Exclusion Criteria
We excluded any participants from health care providers whose age below18 years has any psychological disorders.

Statistical Analysis
Statistical analysis was performed using Statistical Package for the Social Sciences (SPSS) version 22 (SPSS, Chicago, IL, USA). Comparisons of differences between the groups were done using chi-square and 2and results were considered significant difference at P < 0.05.

Saudi Arabia Egypt
; Article no.JPRI.65673 All participants were provided with clear and easy understand information about the research paper in order to allow them to make an informed and voluntary decision about their participation. Filling the questionnaire was considered their agreement Person selection to participate in the research was conducted through convenience sampling, non-probability All participants from both genders should be from health care providers who are working in dical clinics and health care centers during first of November 2020 till end of December 2020. The age of participants from 18 We excluded any participants from health care providers whose age below18 years-old or who Statistical analysis was performed using Statistical Package for the Social Sciences (SPSS) version 22 (SPSS, Chicago, IL, USA). Comparisons of differences between the groups -sample t-tests and results were considered significant % HCWs who answered the question about the types of face mask used during COVID
Universal mask protects against infection and reduces the risk for resurgence during relaxation of social distancing measures [16]. Study in University of Maryland said that wearing surgical masks in public could help slow COVID-19 pandemic and masks limit the spread of influenza, rhinoviruses and coronaviruses [17] and intercept coronaviruses during coughing [18]. A meta-analysis in China showed that surgical masks and N95 respirators were similarly effective in preventing influenza-like illness among HCWs, but they suggest that N95 respirators not be recommended for the general public or medical staff who are not in close contact with influenza or suspected patients [19]. Case-control study in five Hong Kong hospitals (241 non-infected and 13 infected staff) were surveyed regarding their use of masks, gloves and gowns, and their hand washing. About 27% of staff who used all four measures were not infected, while all infected staff omitted at least one measure. The significant result for catching infection only appear with staff who did not wear masks compared with those who did [20]. Other study in University of Hong Kong Polytechnic (2005) showed that N95 mask induce significantly different temperature and humidity in the microclimates of the facemasks, that affect the heart rate and cause thermal stress and discomfort [21].
In our study, the most area has been affected in the body from wearing PPE are hands ( Fig. 4). In the study of HU et al. [5] revealed that the HCWs who wearing latex gloves were more than our participants (88%) and they are reported some adverse skin reactions, such as dry skin (55.7%), itching (31.2%), rash (23.0%), and chapped skin (21.3%) [5]. Another study found that adverse skin reactions due to wearing latex gloves for 6 hours in a period of 9 months were dry skin (73.4%), itch (56.3%), rash (37.5%), and wheals (6.3%), while wearing of plastic gloves did not show skin reactions. There was no significant difference in adverse skin reactions due to sex, race, or profession [4].  (Fig. 5). Another study revealed that one year prevalence of hand eczema (21%) due to daily hand washing with soap > 20 times at work, 45% used hand disinfectants > 50 times and 54% wore nonsterile gloves for >2 hours [24]. Other study reported that 70% alcohol solutions (ethanol, n-propanol, isopropanol) demonstrated virucidal activity but ethanol with 30-second exposure has superior activity than others [23,25]. About 73% of the HCWs used liquid soap and they showed skin problems [15]. About 33.3% & 27.3% of participants from KSA & Egypt did not show any skin changes after using sanitizers or washing hands frequently, skin dryness (55.1% & 63.6%), skin rash & redness (21.3% & 22.7%), eczema (10.7% & 13.6%) respectively (Fig. 6). Emami reported that frequent use of alcohol based products can result in skin dryness and irritation [26]. Rundle reported that 98% of cases had irritant contact dermatitis due to frequent hand washing [9].

CONCLUSION
From this study we can conclude that there was a significant increase among HCWs in Egypt either in wearing surgical and N95 masks or in wearing surgical and plastic gloves when compared to Saudi HCWs. There were some variations by increment or reduction in the side effects on hands and face due to wearing PPE among HCWs among KSA and Egypt. Skin dryness is the most adverse reaction due to using sanitizers (specially alcohol 70% in form of gel).

DISCLAIMER
The products used for this research are commonly and predominantly use products in our area of research and country. There is absolutely no conflict of interest between the authors and producers of the products because we do not intend to use these products as an avenue for any litigation but for the advancement of knowledge. Also, the research was not funded by the producing company rather it was funded by personal efforts of the authors.

CONSENT
As per international standard or university standard, respondents' written consent has been collected and preserved by the author(s).

ETHICAL APPROVAL
This study has been reviewed and approved by the research Ethical Committee (REC) at the University of Hail with letter number Nr.16784/5/42 dated 23/03/1442H.